August 2011, Volume 61, Issue 8

Special Communication

Towards behavioural sciences in undergraduate training: A core curriculum

Asma Humayun  ( Department of Psychiatry, Rawalpindi Medical College, Rawalpindi. )
Michael Herbert  ( Behavioural Medicine, International Medical University, Kuala Lumpur, Malaysia. )


There is strong evidence to link biological, behavioural, psychological, and social variables to health, illness and disease. But this knowledge has not been successfully incorporated into standard medical practice. There is a general accord that a simple disease-based model of clinical practice is inadequate and that there is need to change the approach of doctors to include a better understanding of behavioural issues. The need to integrate Behavioural Sciences as an integral component of medical training is well recognised. PMDC initiated these efforts in 2005 but since then little progress has been made towards developing a core curriculum. This aim of the present article is to initiate a concerted effort towards this direction in Pakistan. We have outlined specific objectives keeping the recommended domains for BS in mind. In addition, knowledge and skills-based learning outcomes have also been defined.
Keywords: Medical Ethics, Psychosocial, Human development, Mental health, Communication.


"In almost all countries, the education of health professionals has failed to overcome dysfunctional and inequitable health systems because of curricular rigidities, professional silos, static pedagogy (ie the science of teaching), insufficient adaptation to local contexts, and commercialism in the professions. Breakdown is especially noteworthy within primary care, in both poor and rich countries."1 In a similar vein, the US Institute of Medicine (IOM) reported that "although the scientific evidence linking biological, behavioural, psychological, and social variables to health, illness, and disease is impressive, the translation and incorporation of this knowledge into standard medical practice appears to have been less than successful."2
The bio-psycho-social model3 provided a paradigm shift in medical practice. It is well recognised that Behavioural Sciences (BS) should become an integral component of medical training.4 Indeed, the PMDC (2005) has also accepted the need to incorporate such training in medical education.5 However, a recent review found that little progress has been made in improving the quality and quantity of behavioural sciences\\\' teaching in medical schools, even in developed countries.6 Their findings suggest that there are no uniform guidelines, well established curricula, training modules or materials. They also highlighted a severe shortage of adequately trained teachers. Some of these issues have been addressed in a recent textbook by Humayun & Herbert7 which focused on training and learning in BS in a Pakistani context.
This aim of the present article is to initiate a concerted effort to develop a standardised curriculum for BS in Pakistan. There is an urgent need to define an essential core to meet the general objective of undergraduate curriculum.5 The IOM recommended six topic domains for the behavioural sciences in medical education:2
1. Mind-body interactions: To learn about the interaction between biological, behavioural, psychological and social factors which contribute to health issues.
2. Patient behaviour: To understand behaviours that put patients at risk and help them develop interventions for behaviour change.
3. Physician role and behaviour: To highlight how the doctor\\\'s personal background, beliefs and attitude influences patient care.
4. Physician-patient interaction: To learn effective communication with patients and their families.
5. Social and cultural issues in health care: To provide appropriate care to patients with differing social, cultural, and economic backgrounds.
6. Health policy and economics: To help students understand their health-care system.
Published literature on the role of BS in medical training is scanty and largely from developed countries. In the UK the General Medical Council (2009) set out specific objectives for BS in undergraduate training.5 This has been modified as follows:
Apply psychological principles and knowledge to medical practice:
1. Explain normal human behaviour at an individual level.
2. Apply psychological concepts to explain the varied responses of individuals to disease.
3. Explain psychological factors that contribute to illness, the course of the disease and the success of treatment.
4. Discuss psychological aspects of behavioural change and treatment compliance.
5. Discuss adaptation to major life changes, such as bereavement.
6. Identify appropriate strategies for managing patients with emotional difficulties.
Apply social science principles and knowledge to medical practice:
1. Explain normal human behaviour at a societal level.
2. Discuss sociological concepts of health, illness and disease.
3. Explain sociological factors that contribute to illness, the course of the disease and the success of treatment.
4. Discuss sociological aspects of behavioural change and treatment compliance.
5. Explore issues relating to health inequalities, the links between socio-economic factors and health.
Communicate effectively with patients and colleagues:
1. Communicate clearly, sensitively and effectively with patients, their families, and colleagues.
2. Communicate clearly, sensitively and effectively with individuals regardless of their age, socio-cultural backgrounds or their disabilities.
3. Apply the principles of non-verbal communication in the medical consultation.
4. Communicate appropriately in difficult circumstances, such as when breaking bad news, and when discussing sensitive issues, such as sexual practices, smoking or obesity.
5. Deal effectively with emotional reactions of patients.
6. Apply the techniques of counselling in everyday medical practice.
Apply ethical principles to medical practice:
1. Discuss and apply the principles of medical ethics with special emphasis on cultural issues.
2. Explain the code of ethics set by the PMDC.
3. Demonstrate awareness of the clinical, administrative and social responsibilities of the doctor.
4. Respect all patients regardless of their age, gender, lifestyle, beliefs, religion, culture, disability, ethnicity or socio-economic status. Graduates will respect patients\\\' right to hold religious or other beliefs, and take these into account when relevant to treatment options.
5. Recognise and respect the rights of patients and colleagues.
6. Understand ethical responsibilities involved in protecting and promoting the health of individual patients and community including vulnerable groups.
The authors suggest at least 6 modules to meet the objectives above. A brief introduction and rationale for individual module is included below. We have identified key themes and topics for each module. In addition, knowledge and skills-based learning outcomes have also been defined. We have not made any comments on teaching methodology because we are well aware of the diverse variation of resources in different medical institutions but we have made an active effort to maintain a patient-centred approach throughout this curriculum.
1. Communication skills
2. Human development
3. Social influences in health care
4. Psycho-social aspects of physical illness
5. Medical ethics
6. Mental health care
1. Communication skills:
Since communication plays a central role in medical practice, formal training in such skills is strongly recommended as an integral part of the medical

curriculum.5,9 A widely used model of medical consultation suggests that essential components for effective communication involve the skills of developing a relationship, collecting information and giving information.10 Then there are more complex communication tasks e.g., breaking bad news. The need for formal training to do so is well established.11 To foster a holistic approach towards their patients, doctors should be able to deal with emotional reactions of patients. To do this, simple forms of essential psychological interventions (counselling techniques) and other common intervention (Reattribution Technique, introduction to Cognitive-Behaviour Therapy etc) should also be incorporated.
2. Human development:
The role of the basic domains of psychology (e.g. development, cognition, learning) for teaching BS is well established.12

These are essential to describe the mechanisms by which behavioural and social processes interact with biological functions in health. It, therefore, provides the scientific framework for an integrated bio-psycho-social curriculum. Chur-Hansen, et al,13 studied the challenges for BS teaching and concluded that there is \\\'domination of the biomedical model without a corresponding recognition of psychology as science\\\' around the world. We, too, need to recognise the potential contributions of psychologists as health care professionals and work towards developing a multi-disciplinary faculty for teaching BS.
3. Social Influences in Health Care:
The WHO definition of health clearly defines that a complete state of health cannot be achieved without \\\'social well being\\\'.14

This adds huge responsibility for medical trainers to prepare doctors competent to recognise and deal with social influences of healthcare. The Lancet Commission (2010) notes that, \\\'In view of the huge diversity of health systems, the challenge is to adapt competency-based goals for local effectiveness rather than to adopt models from other contexts that might not be relevant\\\'.1
4. Psycho-Social Aspects of Physical Illness:
PMDC recognises the need for an integrated curriculum so that knowledge of different sciences can be applied in a systematic manner to formulate/manage or develop individual cases.

Clinical applications must consider both the diseases of organs (parts of the body) and processes (functions of systems) in a synergistic fashion.15 Psychological processes and social influences affect physical health. They do this via bodily systems, such as the neuroendocrine and immune systems or via health behaviour. The WHO pointed out that smoking, an unhealthy diet and physical inactivity are the modifiable risk factors for the huge burden of non communicable diseases in south Asia.16 Therefore, training in strategies to modify behaviour is essential. Many physical disorders are caused by or made worse by psychological factors. It is also strongly recommended that ­particularly in the realm of cardiovascular medicine.17 Common or \\\'difficult to manage\\\' psychophysiological disorders should be included in the curriculum e.g., \\\'medically unexplained symptoms\\\'. In addition, the role of psychosocial aspects of e.g., palliative care, trauma and violence, self harm and psychosexual disorders cannot be ignored.
5. Medical Ethics:
The role of medical ethics in undergraduate education is well recognised.9,18

Despite that, it is worrying that knowledge of medical ethics and its application in clinical work has been reported to be poor in our setting.19,20 Medical ethics, which deals with how we should or should not interact with patients and colleagues, lies at the heart of daily clinical practice. If doctors are not taught to think about their ethical responsibilities, then there is little to curb an assumed right to do whatever they want. This module attempts to redress that educational imbalance. Students must understand the basic principles governing ethical aspects of clinical practice, their application and limitations. In our view, duties and responsibilities of medical students and doctors need to be addressed in the curriculum. That includes clinical, administrative and social responsibilities. Issues related to research, financial matters and dealing with pharmaceutical industry should also be emphasised. Ethical conflicts that are of growing concern to our healthcare must be included. One such area is that of illegal kidney trade which is grossly exploiting the most vulnerable sections of the society.21
6. Mental Health Care:
There are many misconceptions among health professionals about the concept of mental health.

Some confuse it with mental illness and therefore focus on the domain of \\\'Psychiatry\\\'. As a result, public health aspects especially issues relating to prevention and promotion of mental health are neglected in everyday medical practice. Let us, once again, refer to the definition of health which clearly implies that mental health is an integral part of health.14 As with physical health, mental health is also more than just the absence of mental illness. Roughly, a third of consultations in primary care have a significant mental health component.22
Interestingly, Behavioural Sciences is the only subject which helps link these three domains of \\\'physical\\\', \\\'mental\\\' and \\\'social\\\' with each other. As for mental disorders, Murray & Lopez23 established a huge burden of mental disorders but overall the contribution of mental health problems towards the global burden is projected to continue to rise alarmingly.24 Sadly, the neglect of mental health issues also continues despite evidence of the high prevalence of mental disorders, the substantial burden on individuals and families and the availability of effective treatments.25 Discrimination and violations of the human rights of the mentally ill have been reported from most countries.26 For all these reasons, we propose that a separate module on the basis of mental health be included in this curriculum.
The recommendations made above are based on the authors\\\' experience of teaching BS to medical students in developed and developing countries. Naturally, it is to be expected that other teachers and healthcare professionals may wish to include other topics, not mentioned here, or to de-emphasise some of the suggestions we have made.27 That is only to be expected and is welcome. We repeat that our main aim is to start a discussion so that medical practice in Pakistan can become even more holistic and humane. Such a discussion should involve not only current medical educators but other professional bodies with a potential interest in the area. This could include psychologists, sociologists, anthropologists and nurses among others. We await any comments with interest.


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