Population Health: Behavioral and Social Science Insights

By Jason M. Satterfield and Patricia A. Carney

Abstract

Although some see today as the "golden age" of medical education, the impressive advances in educational science and pedagogy have not created a physician workforce suited to meet the needs of society. Medical school admissions still do not reflect the diversity of patients served, and specialty disciplines (e.g., radiology, dermatology) are over-subscribed, while primary care is underselected by medical graduates. Despite policy changes such as the prevention mandate of the Affordable Care Act, medical school curricula spend comparatively little time on behavioral science and often fail to adequately prepare learners for practicing health care in complex, interprofessional teams. Recent movements to incorporate more workplace learning, quality improvement, and systems science hold promise for future trainees, as do advances in behavioral science and medical education. With the addition of a substantial behavioral science component to the Medical College Admissions Test (MCAT 2015), trainees are likely to arrive with a higher level of preparation and readiness to quickly master and clinically translate social and behavioral science constructs if given the right learning environment and supportive institutional cultures. A more behaviorally and socially sophisticated graduate may be better prepared to deliver high quality, culturally competent care while maintaining a sense of professional and personal resilience in the face of an evolving and challenged health care system. A critical re-examination of each medical school's "social contract" to meet societal needs paired with the impressive advances in medical science hold great promise to enrich and improve the physician workforce of the future.

Introduction

Undergraduate medical education has been undergoing a much needed transformation to better prepare learners to provide care in complex health systems and to address anticipated workforce needs. Currently, 141 allopathic and 30 osteopathic U.S. medical schools are training over 82,000 students; more than 18,000 new physicians graduated in 2013. These numbers will steadily rise as medical school class sizes grow and new medical schools are created.¹ Curricular structure and pedagogy have also been evolving with more schools challenging the classic Flexnerian structure, where the first 2 years are spent learning basic science and the last two in clinical practice apprenticeships.^2,3 Didactic lectures are being replaced with "learner-centered small groups" and "flipped classrooms" where didactic content is presented online, and classroom time is focused on interactive case-based exercises.⁴ Technology has further transformed medical education with the introduction of Massive Open Online Courses (MOOCs), iBooks, simulations, and other interactive, technology-based learning tools.^5,6 In fact, so much has improved from a pedagogical perspective that our current era has been called the "golden age of medical education."⁷

Despite these advances, our vast, expensive, and complex medical education system has failed to produce a physician workforce capable of addressing the leading determinants of health or meeting the health care needs of our communities. The current physician workforce is too small, too specialized, unprepared to work in interprofessional teams, and ill equipped to manage chronic diseases or robustly promote prevention.^7-10

Despite spending more on health care than any other nation, the United States ranks 27th in life expectancy and 25th in infant mortality.^11-12 As a recent Institute of Medicine (IOM)/National Research Council report showed, obesity, diabetes, sexually transmitted infections, teen pregnancy, drug use, and motor vehicle accidents contribute to both chronic and acute conditions and are highly influenced by complex social, behavioral, and political factors. In addition to shortcomings in medical education, lack of reliable access to health care, under-emphasis on primary care and prevention, income inequality, and policy shortcomings all contribute to a failure to protect the health of the public.¹³

What is currently needed of undergraduate medical education is to create a 21st century physician workforce that is able to improve the health of patients and communities.^7,9,14 Medical schools should additionally refocus research priorities on areas that will alter public health and patient outcomes, rather than focusing primarily on areas that have little if any utility for the majority of the population. The mission of medical education should represent a balance between workforce preparation and research suited to the needs of our communities and the Nation overall.

In this chapter, we examine challenges and recent innovations that are directly influencing the physician workforce. We address three critical questions regarding the current state of medical education: (1) Are we training the right people (workforce composition)? (2) Are we teaching the right kind of content and competencies (workforce knowledge and skills)? (3) Are we teaching using the best techniques (workforce training methods)? We propose that behavioral and social sciences (BSS) offer important insights into both the causes and potential solutions for each of these questions. Notable educational and key BSS innovations are described in ways that highlight important transformations yet to come and point to next steps in training the physicians our communities need and deserve.

Question 1: Are We Training the Right People?

Public investment in physician training should motivate medical schools to be held more accountable to societal needs.^9,15-18 However, while the number of medical schools and medical student graduates has risen considerably, theoretically to meet potential workforce deficiencies, this expansion does not appear to match the evolving health needs of the U.S. population. More, not fewer, primary care physicians are needed to provide care in underserved areas and to newly insured populations, and the characteristics of the physician workforce should more closely match the diversity of the patients and communities being served.^19,20

To better characterize this issue, Mullan and colleagues⁹ undertook a qualitative study designed to create a "Social Mission Score" for each U.S. medical school using the percent of graduates going into primary care, percent working in health professional shortage areas, and percent of minority students enrolled. Overall, scores indicated disappointing performance, particularly from many esteemed and well-resourced medical schools. Public medical schools outperformed private institutions, with the Morehouse School of Medicine receiving top honors. Surprisingly, the amount of National Institutes of Health (NIH) research dollars received was inversely correlated with social mission scores. While notable exceptions were found, where both research and social mission were impressively achieved (e.g. University of Washington, University of Minnesota), transformation in medical schools' missions is needed.

A closer look at shifting population demographics highlights the changes needed within our physician workforce. In 2006, racial and ethnic minorities accounted for 28 percent of the U.S. population, yet only 15 percent of medical students and 8 percent of practicing physicians represented these ethnic/minority groups.^21,22 While the number of underrepresented minorities who were first time enrollees in U.S. medical schools increased by 20 percent from 2006 to 2012, overall enrollment has grown by only 12.4 percent, representing modest gains in minority representation.¹ A disproportionate number of Caucasian and Asian medical students continue to be enrolled in medical schools, while the number of African American male students has declined.¹

Racial and ethnic diversity are not the only areas of concern. In 2010, 12.9 percent of the population was born outside the United States,²³ and 19.4 percent of the population spoke a language other than English at home.²⁴ Currently, there are no national data available on physicians' non-English language skills.²⁵ Although mandated, professional medical interpreters often are either underutilized or not available.^26,27 While matching patient-physician demographics and language may not ensure quality medical care, both dyadic and population discordances have implications for impactful therapeutic relationships, communication, and patient motivation to gain access to care.^28,29 Moreover, demographic discordances provide a compelling argument for medical student learners to understand diversity, race, gender, and other sociocultural factors in addition to core skills in communication, spoken language, and literacy.

Increasing trainee diversity benefits patients and enhances trainees' preparedness to work with minority populations.³⁰ "Pipeline programs" designed to attract more underrepresented students into medical school or training for other health professions have become increasingly common. For example, the University of California, Los Angeles (UCLA) PREP program offers 7 weeks of free training to better prepare disadvantaged students for medical or dental school, including MCAT or DAT preparation, coaching on application development, mentorship in career choice, and clinical preceptorships. Currently, 81 percent of PREP participants are admitted to a health professional school. However, in a State with 46.7 percent racial and/or ethnic minorities, UCLA typically enrolls fewer than 30 percent under-represented minority medical students.^31,32 A better understanding is needed regarding existing social, developmental, and environmental factors that influence admissions and enrollment to medical school so that diversity recruitment efforts can be improved.^33-35 Similarly, recruitment and retention of minority medical school faculty, which likely plays a role in minority student applications, has been challenging with programs to recruit minority faculty having limited effectiveness.^36,37 The percentage of underrepresented minority faculty increased from 6.8 percent (95 percent CI, 6.7 percent-7.0 percent) in 2000 to only 8.0 percent (95 percent CI, 7.8 percent-8.2 percent) in 2010. Only 36 of 124 medical schools (29 percent) had a minority faculty development program in place in 2010.³⁶

Innovative programs, such as the Association of American Medical Colleges' (AAMC's) Holistic Review Project,³⁸ which started in 2007, provides a flexible process of assessing applicants' capabilities using a balanced review of experiences, attributes, academic metrics, and how the applicant might contribute value as a trainee and physician. The project provides admissions-related tools and resources that medical schools can use to create and sustain diversity, while staying abreast of larger national and political circumstances that influence minority recruitment (e.g. the U.S. Supreme Court's Fisher decision^a).

In addition to lacking adequate diversity, medical schools are currently failing to produce enough primary care providers (PCPs), especially those with a desire to work in underserved areas or with stigmatized populations. The National Association of Community Health Centers estimates that one in five individuals currently lack adequate primary care because of physician shortages, which are severe in rural communities.^39-41 Federally supported community health centers similarly report recruitment and retention failures, despite such incentives as loan repayment programs.^42,43 Future estimates predict a nationwide shortage of 40,000 PCPs by 2025.⁴⁴

Overall, only 26 percent of medical graduates report they intend to work with underserved populations, and even fewer intend to work in health professional shortage areas (HPSAs).41 In a study of graduating internal medical residents in California between 2000 and 2003, only 4.7 percent intended to practice in HPSAs, 15.1 percent intended to practice in underserved areas, and 25.2 percent intended to practice in public hospitals.⁴⁵ Among those who currently work in underserved areas, minority physicians are disproportionately represented.^46,47

Although the AAMC encouraged medical schools to increase their class sizes by up to 30 percent,⁴⁸ the proportion of students who go into primary care ranges widely; and without additional residency training slots, it is unlikely that increasing the number of medical students will solve the primary care shortage. In addition, the current generation of medical students are more likely to select "lifestyle" specialties such as dermatology, ophthalmology, anesthesia, and radiology, due to more manageable time demands, workload, and more attractive compensation compared to careers in primary care.^49-51 Moreover, medicine has developed specialties that focus more on stage of care (e.g., hospital medicine, palliative care, emergency medicine) rather than comprehensive primary care.⁷ Lastly, other health professionals, such as nurse practitioners and physician assistants, could offer substantial support in primary care delivery even in traditionally underserved areas.^52-55 Currently, most medical students receive limited training in how to work as part of interdisciplinary teams, and physicians have been slow to embrace less physician-centric models of care, despite the present well-known shortcomings of today's U.S health care system.^56,57

Longitudinal integrated clinical clerkships represent a new and rapidly growing approach to improve continuity of care while promoting greater patient and learner-centeredness.⁵⁸ In these models, students typically receive a greater proportion of outpatient training and develop longer relationships with faculty role models who are often primary care providers.⁵⁹ With greater patient continuity and enriched student-patient relationships, students may be more likely to experience the rewards of primary care and the importance of caring for those most in need.

Question 2: Are We Teaching the Right Content and Competencies?

Both the health care needs of the public and systems of care delivery have shifted dramatically over the past century. Medicine has moved from a model of independent private practice focused on the treatment of acute and/or infectious disease to large, team-based organizations heavily involved in the management of chronic diseases.¹⁵ Despite these changes, the U.S. medical education enterprise still focuses primarily on the creation of the "personally expert sovereign physician."⁷

Medical educators have been placed in a seemingly impossible situation. Medical curricula are expected to include foundational material as well as recent scientific advances in biomedicine, while still expanding learners' skill sets to include interprofessional communication, teamwork, systems-based care, quality improvement, population health, informatics, and meta-cognitive skills. Graduates are now expected to become expert clinicians, leaders, and researchers without expanding the traditional 4 years required for the MD/DO degree. We argue that advances in cognitive science (e.g. how we learn), behavioral psychology (e.g. motivation and behavior change), and social science (e.g. understanding communication, group dynamics, and social determinants of health) offer efficient and effective ways to enrich medical curricula and improve clinical practice.

To address the dramatic increase in curricular content demands, educators must restrict material to fundamentals in knowledge and skills that every medical student needs to know to successfully enter residency training in their chosen field. The Accreditation Council for Graduate Medical Education (ACGME) offers guidance in organizing the fundamentals into six broad competency areas: medical knowledge, patient care, interpersonal and communication skills, professionalism, practice-based learning and improvement, and systems-based practice.^60,61 Although initially designed for medical residents, many medical schools have incorporated these competencies into undergraduate medical education. While medical knowledge and patient care fit traditional medical school content, the remaining four competencies have proven challenging, especially in the domains of cultural competence, interprofessional communication and teamwork, and systems-based practice.^62-64 Fortunately, a number of medical schools are deeply engaged in curriculum revisions, and a number of structural, training innovations are being tested (e.g. the American Medical Association [AMA]-supported "Accelerating Change in Medical Education" project). Moreover, recent curricular content guides and development tools are readily available in the foundational sciences.^65-67 While a number of stakeholder issues and competing demands must be considered when selecting curricular content, we suggest that training physicians to improve individual and population health should be paramount. Here, we offer three examples of how medical school content is being improved.

Example 1: Behavioral and Social Sciences (BSS)

Approximately 50 percent of U.S. morbidity and mortality has been directly linked to behavioral and social factors,^68-70 yet BSS content in medical schools remains widely variable and often underrepresented.^71,72 In 2004, the IOM released a report with specific recommendations for the revision of undergraduate medical education designed to address social and behavioral factors affecting the health of the Nation.⁷² This report recommended that medical schools offer a 4-year, integrated BSS curriculum addressing six domains: mind–body interactions in health and disease; patient behavior; the physician's role and behavior; physician–patient interactions; social and cultural issues in health care, and health policy and economics. The report identified 26 BSS topics (Table 1) and called for Federal support to enrich BSS curricula. This content list was later supported by faculty surveys, expert opinion, and a comprehensive textbook review⁶⁷ and used to construct a BSS content "matrix" to be used by curriculum developers and front-line educators alike.⁶⁵

 Table 1. IOM BSS Report (2004): Recommended content areas

In response to the IOM report,⁷² the National Institutes of Health (NIH) and the Office of Behavioral and Social Science Research awarded K07 curriculum development and leadership grants to nine medical schools in 2005 to develop, pilot test, and disseminate BSS curricula. This "BSS Consortium for Medical Education" trained approximately 6,100 medical students and published 135 BSS papers.⁷³ The BSS Consortium was subsequently expanded to 16 schools and broadened its purview to include interprofessional training, implementation science, and training for medical residents and faculty with the potential of reaching more than 12,000 learners.⁷⁴ Table 2 lists both the original K07 schools and the expanded consortium schools, along with examples of educational innovations. A number of other medical schools have published their own models for successfully integrating and improving BSS content.^16,71,75,76 Specific examples of BSS content and competency innovations are provided in Table 2.

 Table 2. Participating medical schools in the BSS consortium for medical education

Note: BSS = behavioral and social sciences; EHR = electronic health record; HIT = health information technology; IOM = Institute of Medicine; IPE—interprofessional education; PBL = problem-based learning; SIM = simulated; TBL = team-based learning; TIP/TOP = teaching consultation program

The Baylor College of Medicine implemented a "Best Intentions Workshop," a session for third year medical students, delivered to more than 400 students over 3 years. This workshop session used the Implicit Associations Test (IAT)⁷⁷ as a trigger for small group-based reflection about physician implicit bias (how doctors may unknowingly perpetuate health care disparities), as well as strategies for managing potential biases. Students with lower self-awareness about personal bias prior to the session showed significant increases in self-awareness after the session (p <0.001). Students also showed significant (p<0.01) increases in agreement that the IAT was effective in increasing awareness of personal bias and for generating small group discussion about it. Sixty-seven percent of students undertaking this program identified alternate strategies for managing bias toward patients at post-session, and distribution of the strategies changed significantly from pre-session to post-session as well (p < 0.01).^78,79

The University of Wisconsin implemented a required four-semester Cultural Perspectives Curriculum with approximately 8 hours of large group and 4 hours of small group instruction across four semesters of the first and second year. Topics included health and illness perspectives of patients and physicians, culture of medicine, and health literacy. Assignments helped students to understand their own health and illness perspectives and biases. In addition, students completed reflective writing exercises, using an electronic portfolio, on an artifact of cultural competence. A required third year Core Day "Skills to Impact Health Disparities" was implemented to teach skills related to cultural competence. A new interdisciplinary experiential course was offered, "Intercultural Communication in Health Care," which included extensive discussion with patients and health care teams and attracted students from medicine, nursing, social work, physician assistant, and physical therapy programs.^b

Although examples of BSS innovations are readily available, global changes in BSS content across schools remains uncertain, and obstacles to change persist. In particular, faculty and learner attitudes may impede further curricular changes. Astin and colleagues found that about one-third of respondents believed that addressing psychosocial factors yielded minimal or no improvement in patient care. Most believed their past psychosocial training was ineffective, and few desired additional training. Low self-efficacy, limited knowledge, insufficient time, and low reimbursement were all perceived as reasons why psychosocial factors are seen as less important relative to other biomedical areas of health and illness. Additional reasons for lack of receptiveness include ineffective teaching methods, poor timing, or failure to demonstrate clinical relevance.^80,81 Ongoing projects from the BSS Consortium for Medical Education and others are addressing both attitudinal as well as structural barriers that limit BSS content and its translation into clinical care—that is, a concerted effort to teach the "right" content based on the health and health care needs of the public.

Example 2: Public Health

Despite the impressive advances in biomedical science and other emerging fields, such as personalized genomic medicine, the largest gains in life expectancy and improved quality of life are attributable to social and environmental interventions.^82,83 In the past century, life expectancy has increased by 30 years, and infant mortality has dropped by 95 percent. For 25 of these years, these improvements are attributable to changes in social and physical environments, such as water and food safety, tobacco interventions, and housing conditions.^84-87 While individual behavior change counseling is and should be taught,⁸⁸ the roles social networks and broader environmental influences play on health behavior are currently underappreciated by physicians.^89,90 A solid grounding in the population sciences, epidemiology, and public health should be a core element of training. Although evidence-based medicine and epidemiology are now standard elements of every medical student's education, ways to change the conditions of daily life to make them conducive to healthy behaviors—what has been called "citizen-centered health promotion"—should be highlighted in the medical school curriculum.⁹¹

The Center for Community Health and Service Learning at the Morehouse School of Medicine provides an interesting example of intensive, meaningful public health training and community engagement.^92,93 In this required, two-semester course, students learn the basic principles of public health, needs assessments, and policy interventions. Students then are assigned to community placements where they participate in needs assessments and the development and testing of interventions. Project examples include a fitness program for adolescent girls at a local middle school, HIV prevention interventions at the YMCA, and third trimester counseling on the benefits of breastfeeding at a community health center. Morehouse School of Medicine was recently ranked number one on the Social Mission Score⁹ and consistently graduates physicians who undertake primary care with a focus on the underserved.

Example 3. Systems Science and Quality Improvement

Health care delivery systems have become vast and complex. Independent or even small group practices are increasingly rare, and regardless of practice setting, advanced skills in treatment referral, care coordination, and billing are routinely necessary. In such large and difficult to coordinate systems, substantial errors, suboptimal care, and lack of access occur.

The IOM reports "To Err is Human"⁹⁴ and "Crossing the Quality Chasm"⁹⁵ were instrumental in highlighting the magnitude and costs of medical errors while moving the focus away from individual incompetence toward system and contextual factors that influence patient safety and health care quality. The 1999 report on medical errors called for the creation of a National Center for Patient Safety within the Agency for Healthcare Research and Quality (AHRQ) and essentially spawned a robust, new field of health care research. Medical centers across the country invested substantial resources in creating a "culture of safety," and ongoing quality improvement projects targeting both micro and macro-level changes are increasingly commonplace.⁹⁶ The 2001 quality of care report highlighted the "chasm" between the current health care delivery system and an ideal one. This report called for sweeping redesigns based on six core aims or features of quality: health care should be safe, effective, patient-centered, timely, efficient, and equitable.⁹⁵

Training programs should intentionally integrate quality aims into medical school curricula.⁷ Examples of new competencies include quality improvement, change management, micro- and macro-systems thinking, measuring and correcting performance, maximizing interprofessional communication and cooperation, using health information technology and the electronic health record to provide optimal care, and promoting patient safety and both team and personal accountability.⁹⁷ A synthesis of these and other potential new competencies (e.g. medical school content) for the modern physician are provided in Figure 1 and will be represented in the new University of California, San Francisco (UCSF) Bridges Curriculum in fall 2015.⁷

To support emerging curricula in quality improvement and patient safety (QI/PS), the Association of American Medical Colleges recently launched the Teaching for Quality (Te4Q) initiative. The Te4Q expert panel report and recent competencies document both support institutional assessments, faculty development, local QI and patient safety initiatives, and provide ongoing mentorship and support.⁹⁸ The program's stated goal is "to ensure that every medical school and teaching hospital in the United States has access to a critical mass of faculty ready, able, and willing to engage in, role model, and lead education in QI/PS and in the reduction of excess health care costs."⁹⁸ Thus far, 11 academic medical centers have participated in the Te4Q pilot to promote QI/PS with all showing changes in continuing medical education, and two demonstrating improvement in clinical outcomes.⁹⁹ Similar initiatives such as the "Retooling for Quality and Safety initiative" seek to integrate QI/PS curricula and interventions into both medical and nursing school curricula.¹⁰⁰

Figure 1. Expanded competencies for the 21st century physician

Question 3: Are We Teaching Using the Best Techniques?

The recent 100-year anniversary of the seminal Flexner report¹⁰¹ triggered a Carnegie-funded, in-depth review of medical education pedagogy including an update of workforce development theories and evidence-based teaching strategies.⁸ Similarly, the American Medical Association, the American Osteopathic Organization, the Association of American Medical Colleges, the Accreditation Council for Graduate Medical Education, the Liaison Committee on Medical Education, and the National Board of Medical Examiners have performed training and/or assessment reviews with the shared goal of improving medical education and clinical competence.^61,102-104 Major conclusions and recommendations of these efforts include: (1) moving away from traditional didactic lectures and using more engaging and interactive teaching formats (e.g. small group discussion, team-based learning, game theory); (2) standardizing core competencies or content with flexibility in tailoring both depth and time-based aspects of the program based on learner competence or career interests; (3) including early (and frequent) opportunities to integrate and apply new content in clinical, leadership, or research settings; (4) teaching "habits of mind and heart" or meta-skills that transfer across content areas and contexts; (5) providing key professional identity formation activities ("workplace learning"), including immersion experiences with high-functioning interprofessional teams; and (6) providing longitudinal experiences with both mentors and patients that deepen learning and enrich emotional and cognitive skills, such as empathy and ethical/moral judgment. In contrast to the ongoing struggles with medical applicant recruitment and inclusion of curricular content, some have argued that medical school pedagogy has never been better.^7,105

Although medical schools seem to be continually revising their curricular structures and teaching methods, we question how much progress has really been made. Traditional 2 x 2 medical school curricula still predominate, with a heavy reliance on didactic basic science instruction in the first 2 years and clinical apprenticeships in the last 2 years. Knowledge retention and application of basic science into clinical care have been perpetual problems.^106,107 Moreover, as the body of knowledge in the basic sciences has exponentially grown, it has become virtually impossible to fit "essential" content into a fixed number of curricular hours. Medical students have likened their learning experience to "drinking from a fire hose" and learning through "intellectual bulimia" where they binge on facts that are later purged on examinations and then forgotten. The amount of information to be learned now exceeds a learner's cognitive ability, strongly implicating the need for new learning and information management strategies and requiring consideration of working memory and cognitive load when delivering content.¹⁰⁸

BSS insights gained from cognitive science and psychology in the realm of "meta-cognitive skills" could be instructive. The skills of critical thinking, elaboration, information management, medical informatics, evaluation of evidence, critical reflection, and independent adaptive or life-long learning will consume curricular time but may ultimately give learners a transferrable skill set that allows them to manage the vast libraries of medical knowledge available at their fingertips.^109-111 Although impressive progress and innovations have been amply demonstrated, many medical schools feel compelled to frontload as much basic science as possible into the first 2 years to improve learner performance on the USMLE Step 1 board exam, typically taken after Year 2 and just before leaners start their clinical rotations in Year 3.¹¹² Structural, pedagogical, and policy changes will need to evolve hand-in-hand.

Fortunately, examples of more "learner-centered" curricula abound in both undergraduate^4,113 and graduate medical education¹¹⁴ along with an impressive diversity of pedagogical innovations, such as team-based learning, clinical simulations, and standardized patient assessments.^5,6,115,116 For example, Indiana University used team-based learning sessions to teach medical ethics around the topics of Informed Consent, Duty to Warn, Futility, and Organ Donation. These highly charged, interactive sessions challenged learners to "solve" complex, real world clinical scenarios within small, competing groups.¹¹⁷ Medical students at UCSF and Stanford receive a three-part "meta-cognitive skills" course to facilitate the transition from classroom learning to clinical apprenticeship learning in clerkships. The Albert Einstein College of Medicine and the Warren Alpert Medical School of Brown University developed a series of standardized patient exercises that address ethics and professionalism and use the Implicit Association Test (IAT) to inform discussions and self-recognition of bias.¹¹⁸

Although most medical schools have adopted competency-based medical education and assessments,^61,63 the potential for tailored learning has lagged. Ideally, when a learner achieves a specified competency, s/he should be allowed to move on to the next level, abandoning time-based curricular programs in favor of competency-based ones. In addition to having more flexibility in use of time, curricula could also be tailored to the strengths and interests of a particular learner, especially in experiences that might better prepare them for modern day medical practice or assist them in identifying a career path. Some students could opt for infectious disease rotations at the public health department, while others might participate in quality improvement projects to reduce 30-day hospital readmission rates. Such varied but essential "workplace" learning is feasible, increasingly common, and will be featured in a number of new medical school curricula.¹¹⁹

One unintended consequence of our current medical pedagogy is the unfortunate reductions in student and resident empathy that occurs over the course of medical training.^120-122 Although motivations for enrolling in medical school vary widely, most students arrive with a genuine altruistic interest and desire to alleviate suffering. Over the course of their training, most learners become burned out, apathetic, and even depressed.^67,123,124 A growing body of literature suggests that attending to emotion and communication skills in medical providers, included as curricular content while additionally used to shape more humane pedagogical approaches, might beneficially impact both patient and provider outcomes and prevent erosion of empathy.^124,125 The skillful detection, understanding, and management of emotions in the self and others may impact learner well-being, satisfaction, and professionalism and may lead to improved patient outcomes.^126-28

The Columbia University College of Physicians and Surgeons developed an intensive "teach-the-teachers" narrative medicine curriculum to sharpen the clinical, teaching, and reflective skills of faculty, while enriching relationships, deepening empathy, and promoting wellness. Narrative medicine integrates medicine and literary studies to "fortify clinical practice with the narrative competence to recognize, absorb, metabolize, interpret, and be moved by the stories of illness."¹²⁹ In the Columbia program, faculty meet regularly to guide and be guided through critical analyses of poetry, short stories, and writing exercises. Results suggest that personal enjoyment and growth occur in addition to meaningful professional transformations and changes in teaching practices.^130-132

Ultimately, there is little question that medical education pedagogy has made extraordinary improvements in using the science of learning to shape new teaching methods. These pedagogies are not only more engaging but are better suited to teaching complex interrelationships and nuanced skills well known to BSS. These pedagogies include team-based learning, small-group discussions, problem-based learning, reflective writing, mentorship, and simulations where students learn instead of being taught.^133-135133-135 Most incorporate the creation of "learning communities" with longitudinal experiences that allow learners to develop group ownership, and both faculty and students can share both the direction and facilitation of learning activities. This "evidence-based teaching" maximizes effectiveness and encourages ongoing learner engagement and the development of leadership skills.^105,136 Our hope is that recent advances in pedagogy can be applied to necessary new content and be experienced by more diverse learners interested in improving the health of the public.

As with any workforce development or training program, environmental, economic, and legislative contexts may greatly alter both the type and rate of medical education innovations that occur. For example, the Affordable Care Act potentially will insure millions of new patients or "customers" of medical systems thereby altering the number and proportion of primary care providers that must be trained. Medical education research continues to test and refine innovative teaching methods and assessment tools, although schools struggle with how to satisfy credentialing bodies, prepare learners for licensure tests, maintain student wellness, and empower learners to want to provide patient-centered care. Advances in BSS curricular content abound, but dissemination and implementation have been slow.^10,73 Two potentially large "landscape changes" are described below—the new Medical College Admission Test (MCAT) and the growing acceptance of interprofessional education and non-physician medical team members. Each have the potential to alter and enrich the impressive, ongoing innovations in medical education and should be viewed as opportunities to support medical education in better meeting the needs of the public.

Nearly every medical school applicant takes the MCAT as part of the admissions process. The current MCAT (in use since 1991) includes four sections: physical sciences, verbal reasoning, a writing sample, and biological sciences. In 2015, approximately one-third of a newly revised MCAT will be devoted to behavioral and social sciences questions. The new subtest, "Psychological, Social, and Biological Foundations of Behavior," will measure BSS foundational knowledge in five core content areas: (1) ways that individuals perceive, think about, and react to the world; (2) factors that influence behavior and behavior change; (3) factors that influence how we think about ourselves and others; (4) ways in which culture and social differences influence well-being; and (5) ways in which social stratification affects access to resources and well-being. Core content in the BSS and other new sections of the MCAT was selected through expert panel consensus and faculty surveys developed and administered by the MR5 (MCAT 5th Revision Committee) beginning in 2008.¹³⁷ BSS representation included members from the NIH-supported BSS Consortium for Medical Education who were instrumental in identifying "what every medical student needs to know."¹³⁸

Although MCAT changes may not alter the composition of medical school applicants or those admitted, there are important global implications. First, pre-medical preparation will most likely be expanded to include training in psychology, sociology, and public health in addition to the traditional foundational sciences such as chemistry and biology. Although this creates an added burden on students, it ensures they all arrive in medical school with minimally sufficient BSS knowledge along with chemistry or biology. Subsequent BSS instruction, even in the first year, can begin at more sophisticated levels and progress more rapidly to complex translation of BSS into clinical experiences. Second, medical school applicants will receive an unequivocal message that BSS constructs (e.g. diversity, disparities, equity, empathy, communication, prevention, behavior) are not only central to medical education but equally valued as part of the foundational preparation for a career in medicine. Although the effects of the new MCAT are yet to be determined, preliminary data from a cross-sectional validity study show that new MCAT scores correlate with older MCAT scores in expected ways and correlate with undergraduate grade point averages, and BSS scores are higher in students who have studied those disciplines.¹³⁹

Interprofessional education (IPE) and the acceptance of more team-based care provide a second example of a transformative landscape change on both national and international levels.¹⁴⁰ Although the notion of collaboratively and concurrently training health professionals from multiple disciplines is not new, recent systematic reviews and studies of IPE suggest it should be more seriously considered as a way to address the triple aim of: (1) improving the patient experience of care (including quality and satisfaction), (2) improving the health of populations, and (3) reducing the per capita cost of health care.^140-142 In general, IPE is well received by learners, can effectively teach teamwork and communication skills, and will likely improve service efficiencies, reduce clinical errors, and improve patient satisfaction.^143,144 Genuine acceptance and scaling up of IPE could have profound implications. In a not too distant future, applicants may be able to apply to a broad health professional program and then choose to specialize in a discipline during training instead of applying to nursing school or medical school and remaining locked into an initial training track. More likely is the addition and/or revision of existing curricula to include team work and communication skills, as well as a better understanding of the roles and abilities of diverse team members. From a patient and public health perspective, health care needs could soon be met by any one of a team of multidisciplinary professionals who are well coordinated and best suited to the task at hand. Rather than seeing IPE as a threat to discipline dominance, medical schools should recognize IPE's promise in meeting the needs of the public and potentially lightening the burden currently placed on physicians.

Implications for Practice

Each of our three central questions—who gets trained, what are they taught, and what teaching methods are used—have indirect yet important implications for clinical practice. Who gets trained (i.e., admitted to medical schools) will directly affect the composition of the physician workforce. Composition shifts may alter what field graduates choose to go into and what populations they are willing to serve.^46,47 Admissions committees have already begun the shift toward "holistic" admissions38 with some de-emphasizing the MCAT and others incorporating new and more equitable interview procedures to assess "non-cognitive" factors (e.g. multiple mini-interview145). Both faculty and student composition should accurately reflect the clinical populations being served and will require a substantial investment in recruitment and retention efforts. Curricular content and teaching methods could be revised to better represent the leading causes of morbidity and mortality while employing strategies learned from educational and cognitive sciences to improve classroom efficiency and learner engagement.^109,111,113 Ultimately, the challenge (and potential reward) rests on a graduate's ability to "translate" classroom skills into clinical practice. Including more required workplace learning opportunities may help with this translational leap.

From a policymaker and Federal funding perspective, it will be essential to align financial incentives (and student financial support) with the goals of training a physician workforce capable of meeting the needs of the public. More primary care residency slots should be funded, but medical centers should also be incentivized to include other types of primary care providers such as nurse practitioners and physician assistants. Similarly, interprofessional training and practice could be promoted by creating a performance rubric that assesses and rewards integrative and coordinated interprofessional care. National accrediting bodies for medical schools and medical specialties (e.g., the Liaison Committee on Medical Education [LCME] and the American Board of Internal Medicine [ABIM]) should be lobbied to include competencies or milestones that reflect the best of behavioral and social sciences and are seen as required competencies necessary for accreditation or credentialing. While global "report cards" remain controversial, the scope of medical school performance categories could be enriched to include more than NIH funding received or percent of applicants admitted. Schools scoring high on "social mission" (i.e., those meeting the needs of the communities they serve) should be recognized and rewarded.

Implications for Research

As with Implications for Practice, each of our three central questions has implications for both clinical and educational research. Who gets trained or admitted to medical school and the career choices these medical school graduates make in terms of their career paths need intense study using longitudinal approaches. The change in the MCAT exam with questions on social and behavioral sciences represents an important investment in understanding knowledge of entering medical students. Building upon this foundation by studying how to construct effective instructional designs that foster both clinical skills development and effective tracking of health behaviors in patients and population will be vital. Even more important will be linking more effective clinical practices in social and behavioral science to trends in social and behavioral population-based health indices. Research in neighborhood design—such as distance to healthier food choices and the installation of parks and areas that promote more exercise and physical activity—are all important topics that merit further development in terms of population-based research and the role physicians can play in conducting this kind of research.

The cognitive neurosciences will certainly advance in identifying more effective approaches to address detrimental health behaviors, such as smoking and alcohol or recreational drug use. With advances in clinical care, understanding how best to get best practices into clinical care will be a top priority. Implementation science will inform both clinicians and health systems about how best to integrate effective strategies into practice, which should be a top research priority. Additionally, getting these new techniques included in both medical school and residency training curricula will be important, as will understanding the best educational approaches that ensure use of these techniques in patient care. In summary, research in both effective educational techniques and in ways to advance clinical practice at both the point of patient care and at the population level will all be vital areas of future research.

An important limitation in advancing best educational practices in the health professions is limitations in funding. Though the Health Resources and Services Administration (HRSA) has supported efforts to understand the contributions that medical education makes, more rigor is needed to fully investigate how changes in medical school admissions influence both effective clinical practice in social and behavioral sciences and career path choices regarding primary care. Unfortunately, the mechanisms for funding educational research are limited. While the NIH typically funds clinical and population research, including studies in the social and behavioral sciences, and the National Science Foundation funds programs to enhance science, technology, engineering, and mathematics (STEM) education in undergraduate education, ongoing funding for research in health professions education is extremely limited. This limitation is, unfortunately, slowing the pace of identifying effective educational strategies for social and behavioral sciences in medicine and other health professions. Addressing this problem should be a top priority for educational leaders and policymakers.

Conclusions

It is clear that the enterprise of medical education worldwide is a rich, robust, and impressive incubator for stunning innovations that could both improve educational processes and address the determinants of health for individuals and communities. The three core questions remain open to debate: (1) Are we training the right people? (2) Are we teaching the right content and competencies? (3) Are we teaching using the best techniques? However, impressive innovations largely derived from the behavioral and social sciences highlight potential solutions to address applicant recruitment, specialty selection, commitment to the underserved, and essential new content and competencies required of the 21st century physician who may be collaboratively treating older, more diverse patients with multiple chronic diseases. Larger landscape changes such as the Affordable Care Act, the new MCAT, and IPE offer examples of how dramatically different medical education may be in just 10 years from now. Our stewardship of this process is vitally important if real change is to occur. This stewardship must include medical educators, scientists, learners at all levels, stakeholders in local communities, health policymakers, health systems administrators, and patients themselves. Medical education can and should be realigned to better meet the Nation's health priorities. Training innovations drawn from the behavioral and social sciences offer one essential pathway to success.

Acknowledgments

Funding for this work was provided by NIH/NCCAM/OBSSR grant 5R25AT006573 and NIH/NCI/OBSSR grants 1R25CA158571-01A1 and 5R25CA158571-02. The opinions presented herein are those of the authors and may not represent the position of the Agency for Healthcare Research and Quality, the National Institutes of Health, or the U.S. Department of Health and Human Services.

Authors' Affiliations

Jason M. Satterfield, PhD, Professor of Medicine, University of California, San Francisco, San Francisco, CA. Patricia A. Carney, PhD, Professor of Family Medicine and of Public Health & Preventive Medicine, Oregon Health & Science University, Portland, OR.

Address correspondence to: Jason Satterfield, PhD, University of California, 1701 Divisadero Street, Suite 500, San Francisco, CA 94115; email: jsatter@medicine.ucsf.edu.

References

• 1. Table 27: Total graduates by U.S. medical school and sex, 2010-2014. Washington, DC: Association of American Medical Colleges; 2013.
• 2. Cooke M, Irby DM, Sullivan W, et al. American medical education 100 years after the Flexner report. N Engl J Med 2006 Sep 28;355(13):1339-44.
• 3. Irby DM, Cooke M, O'Brien BC. Calls for reform of medical education by the Carnegie Foundation for the Advancement of Teaching: 1910 and 2010. Acad Med 2010 Feb;85(2):220-7.
• 4. McLaughlin JE, Roth MT, Glatt DM, et al. The flipped classroom: a course redesign to foster learning and engagement in a health professions school. Acad Med 2014 Feb;89(2):236-43.
• 5. Cook DA, Hatala R, Brydges R, et al. Technology-enhanced simulation for health professions education: a systematic review and meta-analysis. JAMA 2011;306(9):978-88.
• 6. Ruiz JG, Mintzer MJ, Leipzig RM. The impact of e-learning in medical education. Acad Med 2006 Mar;81(3):207-12.
• 7. Lucey CR. Medical education: part of the problem and part of the solution. JAMA Intern Med 2013 Sep 23; 173(17):1639-43.
• 8. Cooke M, Irby DM, O'Brien BC, et al. Educating physicians: a call for reform of medical school and residency. San Francisco, CA: Jossey-Bass; 2010.
• 9. Mullan F, Chen C, Petterson S, et al. The social mission of medical education: ranking the schools. Ann Intern Med 2010 Jun 15;152(12):804-11.
• 10. Satterfield JM, Adler SR, Chen HC, et al. Creating an ideal social and behavioural sciences curriculum for medical students. Med Educ 2010 Dec;44(12):1194-1202.
• 11. Health at a glance 2007. Danvers, MA: OECD Publishing. Available at http://www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-2007_health_glance-2007-en. Accessed October 20, 2014.
• 12. U.S. Burden of Disease Collaborators. The state of U.S. health, 1990-2010: burden of diseases, injuries, and risk factors. JAMA 2013 Aug 14;310(6):591-608.
• 13. Woolf SH, Aron LY, National Academies (U.S.), et al. U.S. health in international perspective: shorter lives, poorer health. Washington, DC: National Academies Press; 2013.
• 14. Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet 2010 Dec 4;376(9756):1923-58.
• 15. Boelen C, Heck JE, World Health Organization. Defining and measuring the social accountability of medical schools. Geneva: World Health Organization; 1995.
• 16. Mitka M. Report: growth of medical schools brings opportunity to redefine their mission. JAMA 2009 Mar 18; 301(11):1114-5.
• 17. McCurdy L, Goode LD, Inui TS, et al. Fulfilling the social contract between medical schools and the public. Acad Med 1997 Dec;72(12):1063-70.
• 18. Schroeder SA, Zones JS, Showstack JA. Academic medicine as a public trust. JAMA 1989 Aug 11;262 (6):803-12.
• 19. Freeman J, Ferrer RL, Greiner KA. Viewpoint: developing a physician workforce for America's disadvantaged. Acad Med 2007 Feb;82(2):133-8.
• 20. Woollard RF. Caring for a common future: medical schools' social accountability. Med Educ 2006 Apr;40(4):301-13.
• 21. Total physicians by race/ethnicity. Chicago, IL: American Medical Association; 2006.
• 22. Annual estimates of the resident population by sex, race, and Hispanic origin for the United States: April 1, 2000 to July 1, 2008. Washington, DC: U.S. Census Bureau; 2008. Available at http://www.census.gov/popest/data/historical/2000s/vintage_2008/index.html.
• 23. Greico E, Acosta Y, de la Cruz P, et al. The foreign-born population in the United States: 2010. Washington, DC: U.S. Census Bureau; 2012.
• 24. Shin H, Bruno R. Language use and English-speaking ability: 2000. Washington, DC: U.S. Census Bureau; October 2003.
• 25. Regenstein M, Andres E, Wynia MK. Appropriate use of non-English-language skills in clinical care. JAMA 2013 Jan 9;309(2):145-6.
• 26. Diamond LC, Schenker Y, Curry L, et al. Getting by: underuse of interpreters by resident physicians. J Gen Intern Med 2009 Feb; 24(2):256 -62.
• 27. Lee KC, Winickoff JP, Kim MK, et al. Resident physicians' use of professional and nonprofessional interpreters: a national survey. JAMA 2006 Sep 6; 296(9):1050-3.
• 28. Cooper LA, Roter DL, Johnson RL, et al. Patient-centered communication, ratings of care, and concordance of patient and physician race. Ann Intern Med 2003 Dec 2;139(11):907-15.
• 29. Fernandez A, Schillinger D, Grumbach K, et al. Physician language ability and cultural competence. An exploratory study of communication with Spanish-speaking patients. J Gen Intern Med 2004 Feb;19(2):167-74.
• 30. Saha S, Guiton G, Wimmers PF, et al. Student body racial and ethnic composition and diversity-related outcomes in U.S. medical schools. JAMA 2008 Sep 10;300(10):1135-45.
• 31. UCLA prep program. Los Angeles, CA: UCLA Office of Diversity, Inclusion, and Outreach. Available at http://www.medstudent.ucla.edu/offices/aeo/prep.cfm. Accessed May 10, 2014.
• 32. U.S. Census Bureau. California State and County QuickFacts. 2012. Available at http://quickfacts.census.gov/qfd/states/06000.html.
• 33. Beacham T, Askew RW, William PR. Strategies to increase racial/ethnic student participation in the nursing profession. ABNF J 2009 Sum;20(3):69-72.
• 34. Brunson WD, Jackson DL, Sinkford JC, et al. Components of effective outreach and recruitment programs for underrepresented minority and low-income dental students. J Dent Educ 2010 Oct;74(10 Suppl):S74-86.
• 35. Rumala BB, Cason FD Jr. Recruitment of underrepresented minority students to medical school: minority medical student organizations, an untapped resource. J Natl Med Assoc 2007 Sep;99(9):1000-4, 1008-9.
• 36. Guevara JP, Adanga E, Avakame E, et al. Minority faculty development programs and underrepresented minority faculty representation at U.S. medical schools. JAMA 2013 Dec 4;310(21):2297-304.
• 37. Rodriguez JE, Campbell KM, Fogarty JP, et al. Underrepresented minority faculty in academic medicine: a systematic review of URM faculty development. Fam Med 2014 Feb;46(2):100-4.
• 38. Addams A, Bletzinger R, Sondheimer H, et al. Roadmap to diversity: integrating holistic review practices into medical school admission processes. Washington, DC: Association of American Medical Colleges; 2010.
• 39. Physician distribution and health care challenges in rural and inner-city areas. Rockville, MD: Council on Graduate Medical Education; 1998.
• 40. Jones C, Parker T, Ahearn M, et al. Health status and health care access of farm and rural populations. Washington, DC: U.S. Department of Agriculture, Economic Research Service; 2009.
• 41. Ricketts TC, Randolph R. The diffusion of physicians. Health Aff 2008 Sep-Oct;27(5):1409-15.
• 42. Access transformed: building a primary care workforce for the 21st century. Bethesda, MD: National Association of Community Health Centers; August 2008.
• 43. Rosenblatt RA, Andrilla CH, Curtin T, et al. Shortages of medical personnel at community health centers: implications for planned expansion. JAMA 2006 Mar 1;295(9):1042-9.
• 44. Colwill JM, Cultice JM, Kruse RL. Will generalist physician supply meet demands of an increasing and aging population? Health Aff 2008 May-Jun;27(3):232-41.
• 45. Ogunyemi D, Edelstein R. Career intentions of U.S. medical graduates and international medical graduates. J Natl Med Assoc 2007 Oct; 99(10):1132– 7.
• 46. Minorities in medicine: an ethnic and cultural challenge for physician training. Rockville, MD: Council on Graduate Medical Education; 2005.
• 47. Komaromy M, Grumbach K, Drake M, et al. The role of black and Hispanic physicians in providing health care for underserved populations. N Engl J Med 1996 May 16;334(20):1305-10.
• 48. Statement on the physician work-force. Washington, DC: Association of American Medical Colleges; 2006. Available at www.aamc.org/workforce. Accessed March 20, 2007
• 49. Ebell MH. Future salary and U.S. residency fill rate revisited. JAMA 2008 Sep 10;300(10):1131-2.
• 50. Hauer KE, Durning SJ, Kernan WN, et al. Factors associated with medical students' career choices regarding internal medicine. JAMA 2008 Sep 10;300(10):1154-64.
• 51. Lakhan SE, Laird C. Addressing the primary care physician shortage in an evolving medical workforce. Int Arch Med 2009;2(1):14.
• 52. Deutschlander S, Suter E, Grymonpre R. Interprofessional practice education: is the 'interprofessional' component relevant to recruiting new graduates to underserved areas? Rural Remote Health 2013 Oct-Dec;13(4):2489.
• 53. Fairman JA, Rowe JW, Hassmiller S, et al. Broadening the scope of nursing practice. New Engl J Med 2011 Jan 20;364(3):193-6.
• 54. Grumbach K, Hart LG, Mertz E, et al. Who is caring for the underserved? A comparison of primary care physicians and nonphysician clinicians in California and Washington. Ann Fam Med 2003 Jul-Aug;1(2):97-104.
• 55. Institute of Medicine. The future of nursing: leading change, advancing health. Washington, DC: National Academies Press; 2011.
• 56. Donelan K, DesRoches CM, Dittus RS, et al. Perspectives of physicians and nurse practitioners on primary care practice. N Engl J Med 2013 May 6;368 (20):1898-1906.
• 57. Patchin RJ. AMA responds to IOM report on future of nursing [press release]. Chicago, IL: American Medical Association; October 5, 2010.
• 58. Norris TE, Schaad DC, DeWitt D, et al. Longitudinal integrated clerkships for medical students: an innovation adopted by medical schools in Australia, Canada, South Africa, and the United States. Acad Med 2009 Jul;84(7):902-7.
• 59. Bell SK, Krupat E, Fazio SB, et al. Longitudinal pedagogy: a successful response to the fragmentation of the third-year medical student clerkship experience. Acad Med 2008 May;83(5):467-75.
• 60. Accreditation Council for Graduate Medical Education. ACGME Outcome Project 2000. Available at http://www.acgme.org. Accessed November 10, 2004.
• 61. Swing SR. The ACGME outcome project: retrospective and prospective. Med Teach 2007 Sep;29(7):648-54.
• 62. Carraccio C, Wolfsthal SD, Englander R, et al. Shifting paradigms: from Flexner to competencies. Acad Med 2002 May;77(5):361-7.
• 63. Frank JR, Snell LS, Cate OT, et al. Competency-based medical education: theory to practice. Med Teach 2010;32(8):638-45.
• 64. Lurie SJ, Mooney CJ, Lyness JM. Measurement of the general competencies of the accreditation council for graduate medical education: a systematic review. Acad Med 2009 Mar;84(3):301-9.
• 65. Behavioral and social science foundations for future physicians. Washington, DC: Association of American Medical Colleges; 2011.
• 66. Association of American Medical Colleges and the Howard Hughes Medical Institute. Report of Scientific Foundations for Future Physicians Committee. Washington, DC: Association of American Medical Colleges; 2009. Available at https://members.aamc.org/eweb/upload/Scientific%20Foundations%20for%20Future%20Physicians%20%20Report2%202009.pdf. Accessed October 20, 2014.
• 67. Satterfield JM, Becerra C. Developmental challenges, stressors and coping strategies in medical residents: a qualitative analysis of support groups. Med Educ 2010 Sep;44(9):908-16.
• 68. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993 Nov 10;270(18):2207-12.
• 69. Mokdad AH, Marks JS, Stroup DF, et al. Actual causes of death in the United States, 2000. JAMA 2004 Mar 10;291(10):1238-45.
• 70. Schroeder SA. Shattuck Lecture. We can do better—improving the health of the American people. N Engl J Med 2007 Sep 20;357(12):1221-8.
• 71. Benbassat J, Baumal R, Borkan JM, et al. Overcoming barriers to teaching the behavioral and social sciences to medical students. Acad Med 2003 Apr;78(4):372-80.
• 72. Cuff PA, Vanselow NA, Institute of Medicine (U.S.). Committee on Behavioral and Social Sciences in Medical School Curricula. Improving medical education: enhancing the behavioral and social science content of medical school curricula. Washington, DC: National Academies Press; 2004.
• 73. Hollar D, Satterfield J, Carney P, et al. The National Institutes of Health Social and Behavioral Science Consortium: an introduction and progress report on UME curricular innovations. Ann Behav Sci Med Educ 2007;13(2), 60-8.
• 74. Enhancing behavioral and social sciences in undergraduate medical education. Bethesda, MD: National Institutes of Health, Office of Behavioral and Social Sciences Research; updated August 2014. Available at http://obssr.od.nih.gov/training_and_education/bss_medical_school/. Accessed October 20, 2014.
• 75. Clough RW, Shea SL, Hamilton WR, et al. Weaving basic and social sciences into a case-based, clinically oriented medical curriculum: one school's approach. Acad Med 2004 Nov;79(11):1073-83.
• 76. Post DM, Stone LC, Knutson DJ, et al. Enhancing behavioral science education at the Ohio State University College of Medicine. Acad Med 2008 Jan;83(1):28-36.
• 77. Greenwald AG, McGhee DE, Schwartz JL. Measuring individual differences in implicit cognition: the implicit association test. J Pers Soc Psychol 1998 Jun;74(6):1464-80.
• 78. Teal CR, Shada RE, Gill AC, et al. When best intentions aren't enough: helping medical students develop strategies for managing bias about patients. J Gen Intern Med 2010 May;25(Suppl 2):S115-8.
• 79. Teal CR, Gill AC, Green AR, et al. Helping medical learners recognise and manage unconscious bias toward certain patient groups. Med Educ 2012 Jan;46(1):80-8.
• 80. Astin JA, Soeken K, Sierpina VS, et al. Barriers to the integration of psychosocial factors in medicine: results of a national survey of physicians. J Am Board Fam Med 2006 Nov-Dec;19(6):557-65.
• 81. Astin JA, Sierpina VS, Forys K, et al. Integration of the biopsychosocial model: perspectives of medical students and residents. Acad Med 2008 Jan;83(1):20-7.
• 82. Achievements in public health, 1900-1999: decline in deaths from heart disease and stroke—United States, 1900-1999. Atlanta, GA: Centers for Disease Control and Prevention; August 6, 1999.
• 83. Ray O. How the mind hurts and heals the body. Am Psychol 2004 Jan;59(1):29-40.
• 84. Adler N, Steward J, Cohen S, et al. Reaching for a healthier life: facts on socioeconomic status and health in the United States. San Francisco, CA: The John D. and Catherine T. MacArthur Foundation Research Network on Socioeconomic Status and Health; 2008.
• 85. Hofrichter R. Health and social justice: a reader on the politics, ideology, and inequity in the distribution of disease. San Francisco, CA: Jossey-Bass; 2003.
• 86. Kawachi I, Kennedy B, Wilkinson R. The society and population health reader: income inequality and health. New York, NY: The New Press; 1999.
• 87. Siegrist J, Marmot MG. Social inequalities in health: new evidence and policy implications. New York: Oxford University Press; 2006.
• 88. Hauer KE, Carney PA, Chang A, et al. Behavior change counseling curricula for medical trainees: a systematic review. Acad Med 2012 Jul;87(7):956-68.
• 89. Larson N, Story M. A review of environmental influences on food choices. Ann Behav Med 2009 Dec;38(Suppl 1):S56-73.
• 90. Pust S, Mohnen SM, Schneider S. Individual and social environment influences on smoking in children and adolescents. Pub Health 2008 Dec;122(12):1324-30.
• 91. Woolf SH, Dekker MM, Byrne FR, et al. Citizen-centered health promotion: building collaborations to facilitate healthy living. Am J Prev Med 2011 Jan;40(Suppl 1):S38-47.
• 92. Buckner AV, Ndjakani YD, Banks B, et al. Using service-learning to teach community health: the Morehouse School of Medicine Community Health Course. Acad Med 2010 Oct;85(10):1645-51.
• 93. McNeal MS, Blumenthal DS. Innovative ways of integrating public health into the medical school curriculum. Am J Prev Med 2011 Oct;41(4 Suppl 3):S309-11.
• 94. Kohn LT, Corrigan JM, Donaldson MS (Eds). To err is human: building a safer health system. Washington, DC: National Academy Press, Institute of Medicine; 1999.
• 95. Institute of Medicine, Crossing the quality chasm: a new health system for the twenty-first century. Washington, DC: National Academies Press; 2001.
• 96. Kroch E, Duan M, Silow-Carroll S, et al. Hospital performance improvement: trends in quality and efficiency—a quantitative analysis of performance improvement in U.S. hospitals. New York, NY: The Commonwealth Fund; 2007.
• 97. Berwick DM, Finkelstein JA. Preparing medical students for the continual improvement of health and health care: Abraham Flexner and the new "public interest." Acad Med 2010 Sep;85(9 Suppl):S56-65.
• 98. Headrick L, Baron R, Pingleton S, et al. Teaching for quality: integrating quality improvement and patient safety across the continuum of medical education. Washington, DC: Association of American Medical Colleges; 2013.
• 99. Davis NL, Davis DA, Johnson NM, et al. Aligning academic continuing medical education with quality improvement: a model for the 21st century. Acad Med 2013 Oct;88 (10):1437-41.
• 100. Headrick LA, Barton AJ, Ogrinc G, et al. Results of an effort to integrate quality and safety into medical and nursing school curricula and foster joint learning. Health Aff 2012 Dec;31(12):2669-80.
• 101. Flexner A, Carnegie Foundation for the Advancement of Teaching, Pritchett HS. Medical education in the United States and Canada; a report to the Carnegie Foundation for the Advancement of Teaching. New York, NY: Carnegie Foundation; 1910.
• 102. Haist SA, Katsufrakis PJ, Dillon GF. The evolution of the United States Medical Licensing Examination (USMLE): enhancing assessment of practice-related competencies. JAMA 2013 Dec 4;310 (21):2245-6.
• 103. Kaplan RM. Health outcomes and communication research. Health Comm 1997;9(1):75-82.
• 104. Skochelak SE. A decade of reports calling for change in medical education: what do they say? Acad Med 2010 Sep;85(9 Suppl):S26-33.
• 105. Norman G. Research in medical education: three decades of progress. Br Med J 2002 Jun 29;324(7353):1560-2.
• 106. Custers EJ. Long-term retention of basic science knowledge: a review study. Adv Health Sci Educ Theory Pract 2010;15(1):109-28.
• 107. Finnerty EP, Chauvin S, Bonaminio G, et al. Flexner revisited: the role and value of the basic sciences in medical education. Acad Med 2010 Feb;85(2):349-55.
• 108. Stead WW, Searle JR, Fessler HE, et al. Biomedical informatics: changing what physicians need to know and how they learn. Acad Med 2011 Apr;86(4):429-34.
• 109. Bordage G. Elaborated knowledge: a key to successful diagnostic thinking. Acad Med 1994 Nov;69(11):883-5.
• 110. Mann KV. Reflection: understanding its influence on practice. Med Educ 2008 May;42(5):449-51.
• 111. Mitchell R, Regan-Smith M, Fisher MA, et al. A new measure of the cognitive, metacognitive, and experiential aspects of residents' learning. Acad Med 2009 Jul;84(7):918-26.
• 112. Battinelli D, Smith L. Correspondence: "Alliance groups respond to proposed changes to USMLE." Acad Int Med Insight 2008;6(4):5.
• 113. Ludmerer KM. Learner-centered medical education. N Engl J Med 2004 Sep 16;351(12):1163-4.
• 114. Carney PA, Eiff MP, Saultz JW, et al. Assessing the impact of innovative training of family physicians for the patient centered medical home. J Grad Med Educ 2012 Mar:16-22.
• 115. Burgess AW, McGregor DM, Mellis CM. Applying established guidelines to team-based learning programs in medical schools: a systematic review. Acad Med 2014 Apr;89(4):678-88.
• 116. Cook DA, Brydges R, Zendejas B, et al. Technology-enhanced simulation to assess health professionals: a systematic review of validity evidence, research methods, and reporting quality. Acad Med 2013 Jun;88(6):872-83.
• 117. Gaffney M, Cottingham A. Four medical ethics team based learning modules. MedEdPORTAL 2012;ID=9268.
• 118. Gonzalez CM, Kim MY, Marantz PR. Implicit bias and its relation to health disparities: a teaching program and survey of medical students. Teach Learn Med 2014;26(1):64-71.
• 119. Chen HC, Sheu L, O'Sullivan P, et al. Legitimate workplace roles and activities for early learners. Med Educ 2014 Feb;48(2):136-45.
• 120. Bellini LM, Baime M, Shea JA. Variation of mood and empathy during internship. JAMA 2002 Jun 19;287(23):3143-6.
• 121. Bellini LM, Shea JA. Mood change and empathy decline persist during three years of internal medicine training. Acad Med 2005 Feb;80(2):164-7.
• 122. Hojat M, Mangione S, Nasca TJ, et al. An empirical study of decline in empathy in medical school. Med Educ 2004 Sep;38(9):934-41.
• 123. Ratanawongsa N, Wright SM, Carrese JA. Well-being in residency: effects on relationships with patients, interactions with colleagues, performance, and motivation. Patient Educ Couns 2008 Aug;72(2):194-200.
• 124. Shanafelt TD, Bradley KA, Wipf JE, et al. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med 2002 Mar 5;136(5):358-67.
• 125. Epstein RM. Mindful practice. JAMA 1999 Sep 1;282(9):833-9.
• 126. Arora S, Ashrafian H, Davis R, et al. Emotional intelligence in medicine: a systematic review through the context of the ACGME competencies. Med Educ 2010 Aug;44(8):749-64.
• 127. Firth-Cozens, J. Interventions to improve physicians' well-being and patient care. Soc Sci Med 2001;52:215– 22.
• 128. Shapiro SL, Shapiro DE, Schwartz GE. Stress management in medical education: a review of the literature. Acad Med 2000 Jul;75(7):748-59.
• 129. Amiel J, Armstrong-Cohen A, Bernitz MJ, et al. Narrative medicine in education and practice. In Feldman, Christensen, Satterfield (Eds.), Behavioral medicine, 4th Ed. New York, NY: McGraw-Hill; in press.
• 130. Balmer DF, Richards BF. Faculty development as transformation: lessons learned from a process-oriented program. Teach Learn Med 2012;24(3):242-7.
• 131. Charon R. Narrative medicine: honoring the stories of illness. New York, NY: Oxford University Press; 2006.
• 132. Engel J, Zarconi J, Pethtel L, et al. Narrative in health care: healing patients, practitioners, profession, and community. Oxford, UK: Radcliffe Publishing Ltd 2008.
• 133. Koles PG, Stolfi A, Borges NJ, et al. The impact of team-based learning on medical students' academic performance. Acad Med 2010 Nov;85(11):1739-45.
• 134. Wald HS, Davis SW, Reis SP, et al. Reflecting on reflections: enhancement of medical education curriculum with structured field notes and guided feedback. Acad Med 2009 Jul;84(7):830-7.
• 135. Wass V, Jones R, Van der Vleuten C. Standardized or real patients to test clinical competence? The long case revisited. Med Educ 2001 Apr;35(4):321-5.
• 136. Green ML. Identifying, appraising, and implementing medical education curricula: a guide for medical educators. Ann Intern Med 2001 Nov 20;135(10):889-96.
• 137. Preview guide for the MCAT 2015 exam (2nd Ed). Washington, DC: Association of American Medical Colleges; 2012.
• 138. Kaplan RM, Satterfield JM, Kington RS. Building a better physician—the case for the new MCAT. N Engl J Med 2012 Apr 5;366(14):1265-8.
• 139. Bereknyei S, Satterfield J, Sein A, et al. A collaborative research model across eleven medical schools and the Association of American Medical Colleges: investigating the predictive validity of the psychological, social, and biological foundations of behavior (PSBB) section of the new MCAT exam. Poster presented at Western Group on Educational Affairs, 2014; Honolulu, HI.
• 140. Framework for action on interprofessional education and collaborative practice. Geneva: World Health Organization; 2010.
• 141. Reeves S, Goldman J, Burton A, et al. Synthesis of systematic review evidence of interprofessional education. J Allied Health 2010 Fall;39(Suppl 1):198-203.
• 142. Institute for Healthcare Improvement. IHI Triple Aim Initiative. Available at http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx. Accessed October 22, 2014.
• 143. Institute of Medicine. Interprofessional education for collaboration: learning how to improve health from interprofessional models across the continuum of education to practice: workshop summary. Washington, DC: National Academies Press; 2013.
• 144. Reeves S, Zwarenstein M, Goldman J, et al. Interprofessional education: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2008 Jan 23;1.
• 145. Eva KW, Rosenfeld J, Reiter HI, et al. An admissions OSCE: the multiple mini-interview. Med Educ 2004;38:314–26.

^a. Refer to syllabus for Fisher vs. University of Texas at Austin, et al. Available at http://www.supremecourt.gov/opinions/12pdf/11-345_l5gm.pdf.

^b. Refer to Diversity Matters, School of Medicine and Public Health, University of Wisconsin-Madison at http://www.med.wisc.edu/diversity/our-vision/38255.

Jason M. Satterfield, PhD, is Professor of Clinical Medicine in the Division of General Internal Medicine, University of California San Francisco. His current interests include the integration of behavioral science in medical education, dissemination and implementation of evidence-based behavioral practices, and emerging mobile health technologies for behavioral health. He is a member of the NIH Social and Behavioral Sciences Curriculum Consortium and the NIH Evidence-Based Practice Training Council. Dr. Satterfield evenly divides his time between ongoing patient care, teaching, and health services research.