Benbassat, Jochanan MD; Baumal, Reuben MD; Borkan, Jeffrey M. MD, PhD; Ber, Rosalie MD, DSc
At the beginning of the 20th century, there was little that physicians could offer their patients beyond caring, empathy, and support. This has dramatically changed since the discovery of insulin and antibiotics, and recent advances, such as surrogate motherhood and organ transplantation, have expanded still further the realm of treatment possibilities.1 However, there is increasing concern that a focus on the biomedical aspects of disease may erode physicians' humanistic attitudes; awareness of social, cultural, and environmental determinants of health; and ability to discriminate between technically possible and morally permissible interventions. In response to this concern, most U.S. medical schools have introduced courses in the behavioral and social sciences (BSS) into their curricula.2,3 Like other authors,4,5 we use the BSS as an all-inclusive term for a wide spectrum of diverse topics (e.g., interviewing skills, medical ethics, introductory courses in sociology, psychology, and anthropology) that are not part of the biomedical programs or clinical clerkships. Courses in the BSS differ in contents, methods, and settings of instruction; however, they all share the common interest of integrating key humanistic and social science principles into the medical curriculum.
Although already identified by Flexner in 1910 as an educational requirement for physicians,6 it was only during the last four decades that the BSS evolved into a distinct discipline with an established place in the medical curriculum.7 Attempts to implement topics in this discipline have met varying degrees of success. On the one hand, many teaching courses (e.g., those described by Almy, Colby, Zubkoff, et al.8) have reportedly achieved their objectives. On the other hand, it has been claimed that “most attempts to integrate the … social sciences into medical education in the U.S. have been only marginally successful,”9 and that “…the acceptance of these disciplines into the medical curriculum has remained uneasy.”10 Others have noted that students find behavioral science theory trivial at best11 or not relevant to medical practice.12 Students have been reported to be “a little contemptuous of the study of social medicine”13 and to believe that “the relationships between psychosocial determinants and health are either so obvious that they require little … explanation, or so fanciful that they … exist only as a psychiatric or sociological delusion.”10 As recently as 1998, students at the University of Nebraska Medical Center were reported to be dissatisfied with instruction in medical sociology and to resist “a critical reflection on their personal attitudes and values.”14
We feel that the difficulties students have in appreciating the various topics of the BSS are worth addressing. Compared with the biomedical courses, those in the BSS are new (see Wegar2 and Badgley and Bloom7 for a review) and their content is still being adjusted to students' needs and to changes in clinical practice. In this paper we review the changes in the main types of BSS courses at Israeli medical schools during the past decades; we suggest reasons medical students have difficulties learning some of these subjects and propose an approach to deal with these difficulties.
The ideas presented in this paper were developed over several years while three of the authors, medical doctors with clinical backgrounds, taught at the medical schools of the Hebrew University Hadassah (HUH), Tel-Aviv University (TAU), Technion–Israel Institute of Technology in Haifa (IIT), and Ben-Gurion University in Beer Sheva (BGU). JB taught patient interviewing at HUH and BGU.15,16 JMB taught sociology and anthropology at BGU, helped coordinate the reform of the behavioral science curriculum at TAU,17 and taught medical anthropology at IIT. RB coordinated the “Introduction to Clinical Medicine” course and taught patient interviewing at IIT.18 This paper is not intended to be a comprehensive review, nor to propose a well-defined and tested model for teaching the BSS in medical schools; it is, rather, a personal analysis of our experiences confronting barriers in communication with students, guided by our belief that the BSS should be part of the medical curriculum. We hope that the proposed approach will be useful in creating a BSS curriculum according to the beliefs and institutional values of the various medical schools.
CONTEXT OF MEDICAL EDUCATION IN ISRAEL
The four Israeli medical schools use a six-year European model of undergraduate education. Their programs include three and a half years of preclinical studies (equivalent to pre-med and years one and two in North American medical schools) and two and a half years of clerkship rotations in various clinical departments (equivalent to years three and four in North America). Admission to one of the 300 spaces available at all four medical schools is highly competitive, with students entering directly after high school, army, or national service.
TEACHING PROGRAMS IN THE BEHAVIORAL AND SOCIAL SCIENCES
Teaching of the BSS may be broadly classified by educational content, methods of instruction, and timing in the curriculum into subject matter-oriented, public health, clinical, and integrated courses. Although not necessarily mutually exclusive, these components appear to have met with different levels of acceptance by students and faculty at Israeli medical schools.
Subject-matter–oriented courses include topics such as “Patients and Doctors in Society”19 and human development from “Womb-to-Tomb,”20 presented as stand-alone lecture courses before the clinical clerkships. Such courses have had mixed acceptance by Israeli students, mostly because of their perceived lack of clinical relevance. The preclinical program at HUH has included a long-standing introductory course in psychology. However, an introductory course in sociology was poorly accepted by first-year students in the early 1970s and was discontinued seven years later. From the mid-1960s until 1999, TAU offered the largest BSS core curriculum of any Israeli medical school. In the first two years of the six-year curriculum, it included courses such as introduction to medical anthropology, history of medicine, medical psychology, and the life cycle. Attendance was often spotty because students were unhappy with the lecture format. They felt that the material held little clinical relevance and that the professional attitudes fostered by some of the lecturers were inconsistent with the behavior of clinicians. These complaints, as well as the need to update course content to better reflect current practice norms, resulted in a major revision of the TAU BSS program in 1999 and in the implementation of the integrated program described below.
At IIT, the preclinical electives “The Psychosocial Aspects of Health,” “Literature and Medicine,” and “History of Medicine” were highly rated by the students; however, the first two were discontinued after the teachers moved to other departments or retired. Core courses on the life cycle and medical anthropology were poorly accepted and have undergone repeated revisions. More recently, “Introduction to Psychology” and “Medical Psychology” were included in a revised integrated program, which has been implemented at IIT since 1995.
The medical school at BGU was founded with an explicit commitment to a biopsychosocial and a patient-centered/community-centered approach. Still, attempts to teach courses such as “Normal Life Cycle” and “Society, Culture, and Health” between 1974 and 1987 encountered sustained student dissatisfaction despite repeated revisions and changes of teachers. Students appeared to “be bored by information with which they agree, and to reject information with which they disagree.”21 Eventually, most BSS subject-matter–oriented courses were discontinued, and at present they are restricted to first-year electives “History of Medicine” and “Medicine and Law,” a first-year core course “Body and Soul,” and a 20-hour core fifth-year course, “Human Sexuality.”
Public Health Courses
Public health courses include preclinical lectures on and students' exposure to issues such as sanitation, health promotion, and the structure of the national health care system at various community agencies.22 Such courses are taught only sparingly at Israeli medical schools.23 The most extensive exposure was offered at HUH between 1955 and 1979. This three-week course consisted of visits to factories, district health offices, perinatal clinics, food producing and processing plants, and restaurants, as well as lectures and discussions. It was discontinued after a curricular reform assigned its coordination to teachers who placed a higher priority on clinical epidemiology. At TAU, there are occasional lectures in the first year on birth control and smoking cessation. At IIT and BGU, second-year students visit factories, food-processing plants, penal complexes, perinatal clinics, drug addiction centers, and occupational and environmental medicine clinics. Health promotion is also taught at BGU as lectures scattered throughout various second-year courses on cardiovascular, neoplastic, and infectious diseases, and during the family medicine clerkship.
Clinical courses are commonly offered as small-group supervised practice sessions or discussions before9,24,25,26 and during8,17,18,27 the clinical clerkships. They attempt to teach patient interviewing and counseling and how to identify and resolve ethical (e.g., informed consent) or psychosocial (e.g., family violence) problems. Table 1 summarizes the current interviewing skills courses at Israeli medical schools. The courses at TAU, IIT, and BGU include supervised practice sessions. At HUH, such sessions are offered to only about 20% of the class as an elective sixth-year, course so that most HUH graduates have never interviewed patients in the presence of an instructor. At all Israeli medical schools, medical ethics are taught in preclinical lectures and reinforced during the clinical clerkships. At HUH, about 5% of the clerkship is devoted to small-group discussions led by trained ethicist–clinicians. At TAU, students take a 15-hour course in the sixth year. At IIT, ethical dilemmas are discussed in the fourth year in five two-to-four-hour small-group sessions after viewing videotaped simulated doctor–patient encounters, and in the sixth year during two four-hour sessions on “Breaking Bad News.” At BGU, the clinical clerkships include discussions on confidentiality, genetics, informed consent, dialysis, and discontinuation of treatment, in addition to a ten-day workshop in the sixth year, consisting of lectures and small-group discussions.
Some clinically relevant BSS topics have been referred to as “sociology in medicine.”4,28 These topics include emotional and social phenomena that may predispose people to develop disease or to alter their behaviors after disease has occurred. Attempts to teach medical students how to identify and approach various psychosocial problems have used hypothetical,8,24 simulated,18 and real9,27 patients to provide learning opportunities about palliative and end-of-life care29 and domestic violence.25 Such courses are well accepted by students at all four medical schools in Israel. Since 1999, teams of social scientists and clinicians have offered such learning opportunities during clinical clerkships at TAU. For the past 20 years, general internists at IIT have taught a course that exposes students to videotaped simulated patient–doctor encounters in various settings, and is followed by discussions of clinical, psychosocial, and cultural aspects.18 However, to be successful, such programs require considerable investments of time, as well as coordination with expert consultants such as sociologists or psychologists,17,27 development of hypothetical patient problems,8,18 and, mainly, dedicated coordinators. At HUH, a program consisting of small-group discussions of patients' psychosocial problems led by a surgeon and a psychiatrist was discontinued after the latter retired. At BGU such a program27 was discontinued after its coordinators left the medical school.
Integrated courses combine elements of the subject-matter–oriented, public health, and clinical courses. Integration may be horizontal (i.e., among different BSS topics taught during the same year, such as the course “Medicine, Patient and Society” at McGill30). Alternatively, integration may be vertical9,19,31 (i.e., begun early in the curriculum and reinforced throughout the clinical clerkship), such as the “Spine” program, which is being planned at University Colleges of London,32 and the just-completed reforms in the curriculum at Case Western Reserve University School of Medicine.33 Typically, vertically integrated courses vary in content, instructional methods (lectures, small-group discussions, and supervised practice), and timing (before and during the clinical clerkships).
Vertically integrated courses have been implemented at TAU since 1999,17 at IIT since 1995, and at BGU since 1974.21 Subject-matter–oriented courses, interviewing skills, medical ethics, and other clinical programs are taught as described above; content areas, such as public health, health promotion, life cycle, sociology, and anthropology, are taught in scattered lectures and panel discussions together with other learning experiences, rather than in subject-matter–oriented lecture courses. For example, at TAU the ethical issues of pharmaceutical marketing are discussed during the pharmacology course. At IIT, topics such as what it means to be a physician, end-of-life decisions, and transplantation are discussed during the first- and second-year interviewing skills course. At BGU, lectures and discussions on the physician's oath, animal experimentation, crisis management, breaking bad news, and psychosocial aspects in the management of handicapped children are scattered throughout various first- and second-year courses. In addition, some of the small-group research projects in the second-year course on epidemiology consist of social surveys.
BARRIERS TO THE IMPLEMENTATION OF TEACHING PROGRAMS IN THE BEHAVIORAL AND SOCIAL SCIENCES
As in U.S. medical schools,2,7 the teaching of the BSS at all four medical schools in Israel has been subject to student and faculty criticism, frequent revisions, discontinuation of courses, high teacher turnover, and change of course directors. The BSS courses at TAU, IIT, and BGU were initially coordinated by sociologists and anthropologists, and later by physicians of departments of family medicine, internal medicine, and pediatrics. The status of the BSS faculty at Israeli medical schools varies from independent departments of social or behavioral sciences to consultants affiliated to the departments of family medicine or psychiatry, and their levels of participation in the educational process range from none or minimal to lectures and tutoring medical students. Moreover, these courses are still being developed, and their methods and content are continuously being redefined and adjusted. Most probably, the recently introduced integrated courses at TAU and IIT will be similarly subject to revisions. Therefore, we are uncertain whether the teaching models of the BSS at any of the four Israeli medical schools will survive in their present format, let alone prove useful for medical schools in other countries.
Some of these frequent revisions were meant to adapt the BSS courses to evolving norms of clinical practice. However, most of them were attempts to overcome three types of difficulties specific to the teaching of the BSS: perceived inconsistency with the mainstream of clinical reasoning, multiplicity of learning objectives, and failure of social scientists and clinicians to work together.
The mainstream of clinical reasoning attributes human disease to anatomic and biochemical abnormalities and dismisses as irrelevant its psychosocial determinants.8,9 Negative attitudes to the BSS were apparent in a 1981 survey of chairpersons of U.S. clinical departments4 and in a 1995 survey of medical students entering the University of Berne.34 As late as 2001, the institutional culture was blamed as the main barrier to teaching humanistic principles in clinical settings.35 The timing of teaching the BSS probably perpetuates its perceived irrelevance for clinical practice. For example, the impact of a lecture course on “Death and Dying” on first-year students, before they have ever seen any patients, is less than that of a small-group discussion of this topic during the clinical clerkships. Other authors have similarly pointed out that efforts to promote humanistic values by classroom teaching are unlikely to affect behavior unless the teaching is done in the presence of real patients.35
Another source of difficulty derives from the multiple topics included in “medical sociology”4,5 and the “behavioral sciences.”20 Obviously, there is not sufficient time in the curriculum to cover all of these topics, and their inclusion is frequently guided by the availability of teachers rather than by perceived importance.36 A lack of teachers was the only cause for discontinuing some BSS courses at HUH, IIT, and BGU.
Lastly, teaching the BSS is impeded by a failure of social/behavioral scientists and clinicians to work together. The scientific “gaze” of the BSS places them as looking at medicine from the outside, and medical students and faculty may object to the critical tone of this appraisal. It has been claimed that “… some departments of behavioral science have adopted an intellectual stance at times antagonistic to the rest of the medical school, by emphasizing the shortcomings of the profession in its delivery of health care.”9 Some U.S. chairs of clinical departments responding to the 1981 survey even referred to an “anti-physician stance of medical sociology,” and commented, “It is dangerous to let sociologists into medical schools… they cause divisiveness by emphasizing differences in care rather than commonalities.”4 We know of no formal surveys of faculty attitudes to BSS teachers at Israeli medical schools, nor of the degree to which the critical appraisal of health care is the scholarly focus of social scientists in Israel; however, the authors have repeatedly encountered an “us-and-them” stance between clinicians and social scientists, which is difficult to bridge and clearly influences the educational environment.
To approach these three difficulties, we propose adopting Engel's biopsychosocial model37 as a link between the BSS and clinical practice, as a reference for establishing priorities among the various topics of the BSS, and as encouragement for a dialogue between clinicians and social scientists.
OVERCOMING BARRIERS TO TEACHING THE BEHAVIORAL AND SOCIAL SCIENCES TO MEDICAL STUDENTS
In 1980, Rieker and Begun proposed that, “if the social explanation of illness is to become useful in medical education, a … model is necessary … to link between the social sciences and medical practice,”9 and ten years later, Hunt and Sobal3 proposed that such a link could be Engel's biopsychosocial model.37,38 It rests on the premise that, just as the heart cannot be studied in isolation from the respiratory system, so also the function of an individual cannot be understood without considering his or her interaction with others. Unlike the biomedical model of clinical reasoning, the biopsychosocial model accommodates the observed associations between life events and morbidity,39 socio-economic determinants and mortality,40 and physicians' decision-making styles and patients' health outcomes.41
Contrary to the negative attitudes of preclinical medical students,9,10,11,12,13,14,34 there is evidence that, during the clinical clerkships, they perceive positively those physicians who stress the psychosocial aspects of medicine.42 We suggest that students be encouraged to explore the biomedical and the biopsychosocial clinical models in an atmosphere characterized by respect for the worth of these different attitudes, critical reflection on their merits, and students' empowerment to reach their own conclusions. A focus on the differences between these models could promote an understanding that the BSS are clinically relevant and that they supplement rather than oppose the biomedical model of clinical reasoning.
List 1 outlines our proposed priorities for teaching BSS. Engel defines patient interviewing (“the doctor–patient dialogue”) as the only “instrument for investigation of the human realm”43 (i.e., for gaining an insight into the patient's concerns, preferences, and lifestyle), and into the psychosocial determinants that may increase the patient's risk for developing a disease and reduce his or her ability to cope with it. Therefore, as List 1 shows, we suggest that the highest priority in the BSS be assigned to teaching interviewing skills. The goal of such a course is to impart to students the ability to gain an insight into the patient's symptom matrix and into the components of the patient's “human realm.” The course we envisage includes demonstrations of patient- and disease-centered methods of interviewing and supervised practice sessions using real patients.15 It also provides students with opportunities to discuss and reflect on other highly relevant clinical issues that emerge during the interview, such as ethical dilemmas, psychosocial determinants of the patient's illness, overcoming barriers in communication with the patient, illness behavior and sick roles, health-belief models, coping styles, and stress adaptation (see List 1). Preclinical courses in interviewing skills expose students to patients for the first time and usually for only brief periods. During the clinical clerkship, however, students encounter sick people for more prolonged times and observe how doctors speak to them. At this stage, the interviewing skills courses should provide them with opportunities to further develop their own interviewing styles and the ability to break bad news to patients, counsel patients, and approach common ethical dilemmas.16
We are aware that the proposed priorities shown in List 1 is influenced by our belief that the patient–physician relationship is central in health care delivery. Other medical faculties may disagree and opt for a different list of educational priorities, (e.g., one emphasizing the social responsibility of the medical profession, team-based and community-based approaches to health care, or a commitment to distributive justice). Whatever its philosophy, a list of educational priorities is an essential step toward conceptual clarity, defining the BSS core curriculum, and focusing on specific educational objectives. Furthermore, an agreed-upon list of educational priorities that is acceptable to the dean's office and the curriculum committee is a commitment to the attainment of these objectives. Just as it is inconceivable to discontinue a course in biochemistry because of a lack of teachers, so also medical schools should make a sustained effort to maintain a pool of instructors in order to implement an agreed-upon BSS core curriculum.
A BSS core curriculum may attempt to cover as many topics as possible; alternatively, it may be restricted to high-priority subjects and offer the remaining topics as electives.26 The former approach is more likely to initiate interested students into the various BSS disciplines; however, it may be limited by the availability of teachers and curriculum time. On the other hand, a restricted BSS core curriculum focuses faculty effort on the most important learning objectives and is also consistent with current trends, giving students the freedom to direct their own learning44; however, this strategy fails to impart an insight into the various BSS disciplines and into the methods of inquiry that define them as such.
Students need to be shown what to do rather than just be told,3,15 and acquiring a clinical skill entails its demonstration by practicing clinicians. Therefore, teaching clinically relevant aspects of the BSS (e.g., patient interviewing) necessitates having clinical instructors who are comfortable conducting group discussions, familiar with the literature on the doctor–patient relationship, and confident in demonstrating appropriate techniques with real (as opposed to simulated or videotaped) patients. In an ideal situation, clinicians on teaching wards should qualify as role models in addressing both biomedical and psychosocial problems. In many clinical settings, however, this is not the case. There is evidence of widespread deficiencies in doctors' interviewing skills,45,46 and doctors have been found to attach less importance than do their patients to sharing health-related information.47 Despite the apparent acceptance of Engel's biopsychosocial model, academic clinicians often lack the training, background, and inclination to act as effective role models and teachers.
An alternative answer to the question “Who should teach medical students the clinically relevant aspects of the BSS?” is that both clinicians and social scientists should do so. Indeed, there are successful courses in which both complement each other's expertise.9,27 However, Engel has warned that such combinations may inadvertently perpetuate the split between somatic disease and psychosocial problems by implying that the latter lie only within the domain of specialists, such as social workers, psychiatrists, and sociologists, rather than being part of the daily clinical practice of all physicians. Therefore, he argued, a crucial challenge for medical education was to identify and assist in the training of model teacher–clinicians.48
We propose to invite BSS faculty, ethicists, and clinicians to teach in such teacher-training programs, which might foster the development of “social science–clinician” or “ethicist–clinician” teachers. We do not expect that such training sessions will teach clinicians everything there is to know about the BSS. However, we do feel that physicians should have a deeper insight into these disciplines because they are relevant for daily practice. Nor do we assume that the role of BSS faculty in medical schools should be restricted to informing and educating clinician–teachers. However, if BSS scholars want to achieve their mission, they have to appreciate the central place clinical faculties play in shaping students' attitudes. We hope that teacher-training sessions will promote an understanding that medicine is based on both population- and laboratory-based sciences and that BSS scholars and clinicians should join forces in educating a more humane, professional, and effective clinician.
The main barriers to teaching BSS in medical schools are its perceived clinical irrelevance, the multiplicity of learning objectives, and the failure of social scientists and clinicians to work together. We feel that a sensible approach to these problems would be first to focus on and continuously reinforce throughout the curriculum the clinically relevant topics in the BSS; second to agree on a hierarchy of learning priorities; and finally, to train or recruit teachers who are willing to teach and capable of teaching these topics.
Despite the diversity in the BSS curricula at Israeli medical schools, our approach is consistent with the changes described in the BSS courses at these schools over the past decades. First, even though none of the four medical schools has an explicit list of learning priorities in the BSS, faculty members and students share the belief that courses that teach interviewing skills and medical ethics are important. These topics have not only survived the frequent revisions, but are the only courses in the BSS that have expanded at all four Israeli medical schools. Second, there has been a tendency to move from subject-matter–oriented lectures to small-group supervised practice sessions, and from stand-alone courses to lectures or discussions that are integrated with other learning experiences. Third, rather than being confined to the preclinical portion of the curriculum, the various topics of the BSS are also discussed during the clinical clerkships. Finally, teacher-training programs have been offered at BGU since 197449 and at HUH since 2000, where more than 120 clinical faculty members have participated in workshops to train moderators how to handle topics of medical ethics with students during the clinical clerkship rotations.
The uncertain and evolving status of BSS scientists in medical schools may be a drawback to the adoption of our call to define priorities of learning objectives in the BSS for medical students. Some BSS scientists may be reluctant to relinquish control of existing subject-matter–oriented lecture courses, while both clinicians and BSS faculty may refuse to cooperate in defining learning priorities. To overcome this, we suggest that decisions about curricular reforms be based on a dialogue between clinical and BSS scientists. The aim of such discussions should be to reduce tensions, negotiate common educational goals for undergraduate medical education, and define the content of teacher-training programs. As seen at TAU and IIT, discussions of this type can be a positive experience for all participants. Any approach that has educators working together with a common goal of producing more humanistic and reflective physicians is a clear “win–win” experience for all involved.
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