Teaching psychosomatic (biopsychosocial) medicine in United States medical schools: survey findings

Assessing the extent of utilization of biopsychosocial model in doctor-patient interaction in public sector hospitals of a developing country

BACKGROUND

Biopsychosocial (BPS) model has been a mainstay in the ideal practice of modern medicine. It is attributed to improve patient care, compliance, and satisfaction and to reduce doctor-patient conflict. The study aimed to understand the importance given to BPS model while conducting routine doctor-patient interactions in public sector hospitals of a developing country where health resources are limited. The study was conducted in Rawalpindi, Pakistan.

MATERIALS AND METHODS

The study design is qualitative. Structured interviews were conducted from 44 patients from surgical and medical units of Benazir Bhutto Hospital and Holy Family Hospital. The questions were formulated based on patient-centered interviewing methods by reviewing the literature on BPS model. The analysis was done thematically using the software NVivo 11 for qualitative data.

RESULTS

The study revealed four emerging themes: (1) Lack of doctor-patient rapport. (2) Utilization of a paternalistic approach during treatment. (3) Utilization of a reductionist biomedical approach during treatment. (4) Patients' concern with their improvement in health and doctor's demeanor.

CONCLUSION

The study highlights the fact that BPS is not given considerable importance while taking routine medical history. This process remains doctor centered and paternalistic. However, patients are more concerned with their improvement in health rather than whether or not they are being provided informational care. Sequential studies will have to be conducted to determine whether this significantly affects patient care and compliance and whether BPS is a workable model in the healthcare system in the third world.

Hospital-Based Physicians' Intubation Decisions and Associated Mental Models when Managing a Critically and Terminally Ill Older Patient

BACKGROUND

Variation in the intensity of acute care treatment at the end of life is influenced more strongly by hospital and provider characteristics than patient preferences.

OBJECTIVE

We sought to describe physicians' mental models (i.e., thought processes) when encountering a simulated critically and terminally ill older patient, and to compare those models based on whether their treatment plan was patient preference-concordant or preference-discordant.

METHODS

Seventy-three hospital-based physicians from 3 academic medical centers engaged in a simulated patient encounter and completed a mental model interview while watching the video recording of their encounter. We used an "expert" model to code the interviews. We then used Kruskal-Wallis tests to compare the weighted mental model themes of physicians who provided preference-concordant treatment with those who provided preference-discordant treatment.

RESULTS

Sixty-six (90%) physicians provided preference-concordant treatment and 7 (10%) provided preference-discordant treatment (i.e., they intubated the patient). Physicians who intubated the patient were more likely to emphasize the reversible and emergent nature of the patient situation (z = -2.111, P = 0.035), their own comfort (z = -2.764, P = 0.006), and rarely focused on explicit patient preferences (z = 2.380, P = 0.017).

LIMITATIONS

Post-decisional interviewing with audio/video prompting may induce hindsight bias. The expert model has not yet been validated and may not be exhaustive. The small sample size limits generalizability and power.

CONCLUSIONS

Hospital-based physicians providing preference-discordant used a different mental model for decision making for a critically and terminally ill simulated case. These differences may offer targets for future interventions to promote preference-concordant care for seriously ill patients.

Clinicians' perceptions of women's experiences of endometriosis and of psychosocial care for endometriosis

BACKGROUND

Endometriosis is a complex, chronic condition with known psychological and social implications for women. Little is known about clinicians' perceptions of the psychosocial aspects of endometriosis and associated care.

AIM

To describe clinicians' perceptions of women's experiences of living with endometriosis and of the provision of psychosocial care for endometriosis.

MATERIALS AND METHODS

A qualitative approach was taken using semi-structured interviews with eight gynaecologists and four general practitioners who provide care to women with endometriosis in Victoria, conducted by telephone and in person from June to December 2014.

RESULTS

Clinicians' perceptions of women's experiences of endometriosis were consistent with those reported by women, particularly when discussing potential infertility. However, less comprehensive descriptions of the effects of endometriosis on women's work and social life and intimate relationships were observed. Some clinicians asserted that endometriosis is caused by poor mental health. General practitioners positioned themselves as best placed to provide psychosocial care to women with endometriosis; gynaecologists suggested various potential providers but rarely themselves. Most clinicians assessed themselves as not being adequately trained to understand and provide care for the psychosocial aspects of endometriosis; half of the gynaecologists did not believe it was necessary for them to do so.

CONCLUSIONS

The findings of this research demonstrate clinicians' need for further support in the provision of psychosocial care for women with endometriosis, potentially through expanded clinical guidelines and professional development opportunities.

"You kind of want to fix it don't you?" Exploring general practice trainees' experiences of managing patients with medically unexplained symptoms

BACKGROUND

Much of a General Practitioner's (GP) workload consists of managing patients with medically unexplained symptoms (MUS). GP trainees are often taking responsibility for looking after people with MUS for the first time and so are well placed to reflect on this and the preparation they have had for it; their views have not been documented in detail in the literature. This study aimed to explore GP trainees' clinical and educational experiences of managing people presenting with MUS.

METHOD

A mixed methods approach was adopted. All trainees from four London GP vocational training schemes were invited to take part in a questionnaire and in-depth semi-structured interviews. The questionnaire explored educational and clinical experiences and attitudes towards MUS using Likert scales and free text responses. The interviews explored the origins of these views and experiences in more detail and documented ideas about optimising training about MUS. Interviews were analysed using the framework analysis approach.

RESULTS

Eighty questionnaires out of 120 (67%) were returned and a purposive sample of 15 trainees interviewed. Results suggested most trainees struggled to manage the uncertainty inherent in MUS consultations, feeling they often over-investigated or referred for their own reassurance. They described difficulty in broaching possible psychological aspects and/or providing appropriate explanations to patients for their symptoms. They thought that more preparation was needed throughout their training. Some had more positive experiences and found such consultations rewarding, usually after several consultations and developing a relationship with the patient.

CONCLUSION

Managing MUS is a common problem for GP trainees and results in a disproportionate amount of anxiety, frustration and uncertainty. Their training needs to better reflect their clinical experience to prepare them for managing such scenarios, which should also improve patient care.

Junior doctors' experiences of managing patients with medically unexplained symptoms: a qualitative study

OBJECTIVES

To explore junior doctors' knowledge about and experiences of managing patients with medically unexplained symptoms (MUS) and to seek their recommendations for improved future training on this important topic about which they currently receive little education.

DESIGN

Qualitative study using in-depth interviews analysed using the framework method.

SETTING

Participants were recruited from three North Thames London hospitals within the UK.

PARTICIPANTS

Twenty-two junior doctors undertaking the UK foundation two-year training programme (FY1/FY2).

RESULTS

The junior doctors interviewed identified a significant gap in their training on the topic of MUS, particularly in relation to their awareness of the topic, the appropriate level of investigations, possible psychological comorbidities, the formulation of suitable explanations for patients' symptoms and longer term management strategies. Many junior doctors expressed feelings of anxiety, frustration and a self-perceived lack of competency in this area, and spoke of over-investigating patients or avoiding patient contact altogether due to the challenging nature of MUS and a difficulty in managing the accompanying uncertainty. They also identified the negative attitudes of some senior clinicians and potential role models towards patients with MUS as a factor contributing to their own attitudes and management choices. Most reported a need for more training during the foundation years, and recommended interactive case-based group discussions with a focus on providing meaningful explanations to patients for their symptoms.

CONCLUSIONS

There is an urgent need to improve postgraduate training about the topics of MUS and avoiding over-investigation, as current training does not equip junior doctors with the necessary knowledge and skills to effectively and confidently manage patients in these areas. Training needs to focus on practical skill development to increase clinical knowledge in areas such as delivering suitable explanations, and to incorporate individual management strategies to help junior doctors tolerate the uncertainty associated with MUS.

Project ASPIRE: Incorporating Integrative Medicine Into Residency Training

Griffin Hospital, a community hospital affiliated with Yale School of Public Health and Yale School of Medicine, received Health Resources and Services Administration funding to strengthen and improve its combined internal medicine and general preventive medicine residency program by incorporating an integrative medicine curriculum. The purpose of project ASPIRE (Advancing Skills of Preventive medicine residents through Integrative medicine Education, Research and Evaluation) was to create, implement, and evaluate a needs-based, innovative training curriculum in integrative medicine. Through this robust new training, the authors aimed to produce preventive medicine-trained physicians with competencies in integrative medicine to collaboratively work with other integrative medicine practitioners in interdisciplinary teams to provide holistic, patient-centered care. The multifaceted collaborative curriculum was composed of didactics, grand rounds, journal club, objective structured clinical examinations, and two new practicum rotations in integrative medicine. The new practicum rotations included block rotations at the Integrative Medicine Center at Griffin Hospital and the Yale Stress Center. Between 2012 and 2014, three cohorts participated in the curriculum; two of these cohorts included three advanced preventive medicine residents each and the fourth included four residents. Project faculty conducted 14 lectures and journal clubs, and two grand rounds. Six of the ten participating residents (60%) completed integrative medicine clinical rotations. Residents' attitudes toward integrative medicine were evaluated through self-assessment using the Complementary, Alternative, and Integrative Medicine Attitudes Questionnaire; data were analyzed in 2015. This article describes the results of this prospective observational study based on single-institution experience over the course of the 2-year project period.

A Review of 21st Century Utility of a Biopsychosocial Model in United States Medical School Education

BACKGROUND

Current medical practice is grounded in a biomedical model that fails to effectively address multifaceted lifestyle and morbidogenic environmental components that are the root causes of contemporary chronic diseases. Utilizing the biopsychosocial (BPS) model in medical school training may produce competent healthcare providers to meet the challenge of rising chronic illnesses that are a result of these factors. This study explored the current trend of research on the utility of the BPS model in medical education and examined medical school curricula that have explicitly adopted the BPS model.

METHODS

A systematic review of peer-reviewed literature was conducted on the BPS model and medical education since the 1970s using multiple databases. Descriptive analysis was used to illustrate findings regarding the trends of the BPS model in medical education and its utility in specific medical schools in the United States.

RESULTS

Major findings illustrated a growing trend in research on the BPS model in medical education since the 1970s with literature in this area most visible since 2000. The same trend was established for the incorporation of psychosocial or behavioral and social science components in medical education. From our peer-reviewed literature search, only 5 medical schools featured utility of the BPS model in their curricula utilizing variable educational processes.

CONCLUSION

Although literature regarding the BPS model in medical education is growing, the explicit utility of the BPS model in medical school is limited. Our findings can stimulate educational processes and research endeavors to advance medical education and medical practice to ensure that future doctors can meet the challenge of rising lifestyle and environmental associated illnesses.

Efficacy of an internet-based learning module and small-group debriefing on trainees' attitudes and communication skills toward patients with substance use disorders: results of a cluster randomized controlled trial

PURPOSE

To examine whether an Internet-based learning module and small-group debriefing can improve medical trainees' attitudes and communication skills toward patients with substance use disorders (SUDs).

METHOD

In 2011-2012, 129 internal and family medicine residents and 370 medical students at two medical schools participated in a cluster randomized controlled trial, which assessed the effect of adding a two-part intervention to the SUDs curricula. The intervention included a self-directed, media-rich Internet-based learning module and a small-group, faculty-led debriefing. Primary study outcomes were changes in self-assessed attitudes in the intervention group (I-group) compared with those in the control group (C-group) (i.e., a difference of differences). For residents, the authors used real-time, Web-based interviews of standardized patients to assess changes in communication skills. Statistical analyses, conducted separately for residents and students, included hierarchical linear modeling, adjusted for site, participant type, cluster, and individual scores at baseline.

RESULTS

The authors found no significant differences between the I- and C-groups in attitudes for residents or students at baseline. Compared with those in the C-group, residents, but not students, in the I-group had more positive attitudes toward treatment efficacy and self-efficacy at follow-up (P<.006). Likewise, compared with residents in the C-group, residents in the I-group received higher scores on screening and counseling skills during the standardized patient interview at follow-up (P=.0009).

CONCLUSIONS

This intervention produced improved attitudes and communication skills toward patients with SUDs among residents. Enhanced attitudes and skills may result in improved care for these patients.

National survey on psychosocial obstetrics and gynecology curriculum in US medical schools

INTRODUCTION

This study sought to identify how psychosocial topics related to women's health are taught and assessed in the obstetrics/gynecology program of American medical schools, and what issues may prevent or promote their instruction.

METHODS

A questionnaire was distributed to the ob/gyn clerkship director of every US medical school. Directors were asked whether each of four recommended topics were covered in their curricula. They were also asked about barriers to instructing topics not taught, and the importance of these topics.

RESULTS

Out of 136 US medical schools, 57 questionnaires were returned (response rate = 40.4%). In all, 27 schools (48%) include formal training in pregnancy-related mood disorders, 33 (58%) include pre-menstrual syndrome/pre-menstrual dysphoric disorder, 29 (51%) include female sexual dysfunction and 45 (79%) include violence against women. Six schools (12%) listed none of these topics as taught. All but three of the clerkship directors agreed that psychosocial topics are important. The most common reason given for lack of instruction was insufficient time allotted.

CONCLUSIONS

Despite agreement on their importance, many US medical schools do not teach psychosocial aspects of women's health. Addressing the barriers to teaching these topics would help provide medical students with more opportunities to learn about these issues.

Patient-reported outcomes in gastroenterology: clinical and research applications

Patient-generated reports, also known as Patient-Reported Outcomes (PROs), capture the patients' illness experience in a structured format and may help bridge the gap between patients and providers. PROs measure any aspect of patient-reported health (e.g., physical, emotional or social symptoms) and can help to direct care and improve clinical outcomes. When clinicians systematically collect patient-reported data in the right place at the right time, PRO measurement can effectively aid in detection and management of conditions, improve satisfaction with care and enhance the patient-provider relationship. This review article summarizes the latest approaches to PRO measuring for clinical trials and clinical practice, with a focus on use of PROs in gastroenterology.

The teaching of liaison psychiatry

OBJECTIVE

To document performance and satisfaction of medical students in a short course on liaison psychiatry.

METHODS

The emphasis in this optional course is placed on the discussion of clinical cases, bed-side clinical teaching, and a research-oriented part. The "Innovative Teaching Plan" (ITP) is intended to train student-leaders to guide small groups (SG) of students. Trainee performance was assessed by the marks in the final examination, and a reliable and valid tool, the Medical Teaching Quality Questionnaire (MTQQ) was used to document trainee satisfaction. The results of four academic courses are presented in this report.

RESULTS

External experts consulted assured that the content of the course was adequate. It has been completed by more than 200 medical students, and high marks have been obtained by most. Above average scores (AA, "high" or "very high") were given by substantial proportions of students in most items, related to the "relevance" of the subject, the "usefulness of the clinical cases" or the "enhancement of student-teacher interaction". Compared to the first academic course, students' satisfaction has improved. "Enhancement of a researcher's mind" was rated AA by 61.1% of students in the last academic course, and "global satisfaction" by 88.8%.

CONCLUSIONS

Good performance and high satisfaction of medical students was documented in a course on liaison psychiatry. Lessons may be drawn to inform about efficient and effective ways of teaching and learning this subject.

The clinical application of the biopsychosocial model in mental health: a research critique

Engel applied the term biopsychosocial to medicine to emphasize the need to take into account the psychologic and social aspects of medical practice. After an overview of the history of the biopsychosocial (BPS) model, we review criticisms of the model to reformulate its deficiencies and then analyze its application in mental health care. The objectives of this paper are 4-fold: (1) to examine the use of the BPS model since Engel's 1977 article to the present; (2) to examine the reasons for the popularity of the BPS model as well as the problems it faces when applied to mental health care; (3) to introduce two instruments, the International Classification of Functioning, Disability, and Health and the INTERMED, which implement the BPS model; and (4) to show why the BPS model is not yet a model of mental health practice. A total of 62 publications were retrieved and reviewed in the ScienceDirect, PubMed, and Scopus databases, and 32 of them were eventually included in this review. This is the first review of the studies published that applied the BPS model in mental health in the last 33 yrs. These criticisms are used to construct a more workable vision of the BPS model of clinical practice.

A conceptual model for interprofessional education: The international classification of functioning, disability and health (ICF)

A shared language and conceptual framework is essential to successful interprofessional collaboration. The World Health Organization's International Classification of Functioning, Disability and Health (ICF) provides a shared language and conceptual framework that transcends traditional disciplinary boundaries. This paper will familiarize readers with the ICF and describe the biopsychosocial perspective that is adopted in its conceptual framework and language. The presentation of a case study will illustrate how the ICF can enhance interprofessional learning by promoting a multidimensional perspective of an individual's health concerns. The case study will also highlight the value of the shared language and conceptual framework of the ICF for interprofessional collaboration. It is argued that a strong foundation in the principles exemplified by the ICF may serve to enhance interprofessional communication, and in so doing, encourage involvement in interprofessional collaboration and healthcare.

Engel's biopsychosocial model is still relevant today

In 1977, Engel published the seminal paper, "The Need for a New Medical Model: A Challenge for Biomedicine" [Science 196 (1977) 129-136]. He featured a biopsychosocial (BPS) model based on systems theory and on the hierarchical organization of organisms. In this essay, the model is extended by the introduction of semiotics and constructivism. Semiotics provides the language which allows to describe the relationships between the individual and his environment. Constructivism explains how an organism perceives his environment. The impact of the BPS model on research, medical education, and application in the practice of medicine is discussed.

Integration of the biopsychosocial model: perspectives of medical students and residents

PURPOSE

To examine residents' and medical students' attitudes toward the incorporation of psychosocial factors in diagnosis and treatment and to identify barriers to the integration of evidence-based, mind-body methods.

METHOD

A random sample of third- and fourth-year medical students and residents was drawn from the Masterfiles of the American Medical Association. A total of 661 medical students and 550 residents completed a survey, assessing attitudes toward the role of psychosocial factors and the clinical application of behavioral/mind-body methods.

RESULTS

The response rate was 40%. Whereas a majority of students and residents seem to recognize the need to address psychosocial factors, 30%-40% believe that addressing such factors leads to minimal or no improvements in outcomes. The majority of students and residents reports that their training in these areas was ineffective, yet relatively few indicate interest in receiving further training. Females are more likely to believe in the need to address psychosocial factors. Additional factors associated with greater openness to addressing psychosocial factors include (1) the perception that training in these areas was helpful, and (2) personal use of behavioral/mind-body methods to care for one's own health.

CONCLUSIONS

There is a need for more comprehensive training during medical school and residency regarding both the role of psychosocial factors in health and the application of evidence-based, behavioral/mind-body methods. The current health care structure-particularly insufficient time and inadequate reimbursement for addressing psychosocial factors-may be undermining efforts to improve patient care through inconsistent or nonexistent application of the biopsychosocial model.

A practical assessment of physician biopsychosocial performance

BACKGROUND

A biopsychosocial approach to care seems to improve patient satisfaction and health outcomes. Nevertheless, this approach is not widely practiced, possibly because its precepts have not been translated into observable skills.

AIM

To identify the skill components of a biopsychosocial consultation and develop an tool for their evaluation.

METHODS

We approached three e-mail discussion groups of family physicians and pooled their responses to the question "what types of observed physician behavior would characterize a biopsychosocial consultation?" We received 35 responses describing 37 types of behavior, all of which seemed to cluster around one of three aspects: patient-centered interview; system-centered and family-centered approach to care; or problem-solving orientation. Using these categories, we developed a nine-item evaluation tool. We used the evaluation tool to score videotaped encounters of patients with two types of doctors: family physicians who were identified by peer ratings to have a highly biopsychosocial orientation (n = 9) or a highly biomedical approach (n = 4); and 44 general practitioners, before and after they had participated in a program that taught a biopsychosocial approach to care.

RESULTS

The evaluation tool was found to demonstrate high reliability (alpha = 0.90) and acceptable interobserver variability. The average scores of the physicians with a highly biopsychosocial orientation were significantly higher than those of physicians with a highly biomedical approach. There were significant differences between the scores of the teaching-program participants before and after the program.

CONCLUSIONS

A biopsychosocial approach to patient care can be characterized using a valid and easy-to-apply evaluation tool.

[Attitudes of medical students towards psychotherapeutic treatment and training]

OBJECTIVES

Against the background of insufficient medical care for patients with psychiatric and psychosomatic disorders it is important to ascertain the interests and attitudes of medical students towards mental disorders, psychotherapeutic treatment and training.

METHODS

Medical students (N = 366) in their clinical training were given half-standardized questionnaires about their attitudes towards psychotherapeutic treatments, their career plans, psychosocial distress and sociodemographic characteristics.

RESULTS

There was an overall high interest in psychological distress of patients and in psychotherapeutic treatment methods. Contrary to these findings, however, only few medical students were willing to specialize in psychosomatic medicine, psychiatry or psychotherapy. Psychosomatic and psychotherapeutic career choices were more frequent in women as well as in students who had experienced psychological distress themselves, and who had undergone psychotherapy, and who were less oriented toward economic success and careers.

CONCLUSIONS

Medical students regarded psychological characteristics as generally interesting and important for medical care, but rarely considered specializing in these medical fields after graduation. Potential remedies (e.g., improved teaching of psychosocial competences and psychotherapeutic knowledge, career counselling) are discussed.

Use of mind-body therapies in psychiatry and family medicine faculty and residents: attitudes, barriers, and gender differences

BACKGROUND

Mind-body medicine (MBM) approaches to many health problems have been well documented in the literature, including through multiple meta-analyses. Efficacy has been well demonstrated in conditions such as headache, irritable bowel syndrome, anxiety, fibromyalgia, hypertension, low back pain, depression, cancer symptoms, and postmyocardial infarction. However, an apparent disconnect (ie, translational block) prevents more widespread adoption of such therapies into practice. Biofeedback, relaxation therapy, hypnosis, guided imagery, cognitive behavioral therapy, and psychoeducational approaches are the domain of MBM we examined in assessing physician attitudes, beliefs, and practices.

METHODS

Using a Web-based survey, we obtained responses from 74 faculty and resident physicians in the Department of Family Medicine and the Department of Psychiatry. Our response rate was 69%. We conducted descriptive statistics, bivariate analysis, and multivariate analysis using a logistic regression model. Various statistics were chosen depending on the nature of analyzed variables. Synoptic tables are presented.

RESULTS

Comparing these cohorts, we found little difference between physicians in the two specialties, but substantial reports that barriers to the use of MBM were largely based on lack of training, inadequate expertise, and insufficient clinic time. Lack of expertise and insufficient clinic time were higher among family physicians than among psychiatrists. There was a high interest in both groups in learning relaxation techniques and meditation and lower interest in biofeedback and hypnosis. Female physicians were significantly more likely to use MBM, both with patients and for their own self-care, and were less likely to be concerned that recommending these therapies would make patients feel that their symptoms were being discounted. Female physicians also had significantly higher beliefs about the benefits of MBM on health disorders in several of the conditions examined, with a consistent though nonsignificant trend in others.

The difficult doctor? Characteristics of physicians who report frustration with patients: an analysis of survey data

Background

Literature on difficult doctor-patient relationships has focused on the "difficult patient." Our objective was to determine physician and practice characteristics associated with greater physician-reported frustration with patients.

Methods

We conducted a secondary analysis of the Physicians Worklife Survey, which surveyed a random national sample of physicians. Participants were 1391 family medicine, general internal medicine, and medicine subspecialty physicians. The survey assessed physician and practice characteristics, including stress, depression and anxiety symptoms, practice setting, work hours, case-mix, and control over administrative and clinical practice. Physicians estimated the percentage of their patients who were "generally frustrating to deal with." We categorized physicians by quartile of reported frustrating patients and compared characteristics of physicians in the top quartile to those in the other three quartiles. We used logistic regression to model physician characteristics associated with greater frustration.

Results

In unadjusted analyses, physicians who reported high frustration with patients were younger (p < 0.001); worked more hours per week (p = 0.041); and had more symptoms of depression, stress, and anxiety (p < 0.004 for all). In the final model, factors independently associated with high frustration included age < 40 years, work hours > 55 per week, higher stress, practice in a medicine subspeciality, and greater number of patients with psychosocial problems or substance abuse.

Conclusion

Personal and practice characteristics of physicians who report high frustration with patients differ from those of other physicians. Understanding factors contributing to physician frustration with patients may allow us to improve the quality of patient-physician relationships.

Barriers to the Integration of Mind-Body Medicine: Perceptions of Physicians, Residents, and Medical Students

OBJECTIVE

This study of medical students, residents, and physicians examined their responses to focus group questions in an effort to understand barriers to discussing psychosocial issues and using mind-body interventions to address health issues.

METHODS

Four focus groups were conducted: two with medical students and residents, one with primary care doctors, and one with physicians representing different specialties. Responses were audio recorded and transcribed verbatim.

RESULTS

Factors identified as possible barriers to recognizing the importance of psychosocial/mind-body factors included lack of knowledge of evidence base, inadequate attention paid to the mind-body area in training, perceived lack of competence to use mind-body methods, inadequate time, lack of economic incentive, perception that psychosocial factors are beyond their capacity to control, tendency to perceive conditions as either biological or psychosocial in nature, perception that patients do not want to address psychosocial/lifestyle issues, and cultural beliefs that addressing the psychosocial domain is not within the purview of physicians.

CONCLUSIONS

Despite evidence that psychosocial issues play an important role in health outcomes, students, residents, and practicing physicians reported that methods to deal with these issues are frequently given inadequate attention in medical training, and many physicians feel ill equipped to deal with these issues. In addition, environmental factors, including lack of time, insufficient monetary incentives, and a larger cultural ethos that favors the "quick-fix" over the more difficult task of examining the role of psychosocial factors, appear to serve as significant barriers to medicine's more fully embracing the biopsychosocial model.

Evolution of the biopsychosocial model: prospects and challenges for health psychology

Although advances have been made in specifying connections between biological, psychological, and social processes, the full potential of the biopsychosocial model for health psychology remains untapped. In this article, 4 areas that need to be addressed to ensure the continued evolution of the biopsychosocial model are identified and a series of recommendations concerning initiatives directed at research, training, practice and intervention, and policy are delineated. These recommendations emphasize the need to better understand and utilize linkages among biological, psychological, social, and macrocultural variables. Activities that facilitate the adoption of a multisystem, multilevel, and multivariate orientation among scientists, practitioners, and policymakers will most effectively lead to the kinds of transdisciplinary contributions envisioned by the biopsychosocial perspective.

Core competencies in integrative medicine for medical school curricula: a proposal

The authors present a set of curriculum guidelines in integrative medicine for medical schools developed during 2002 and 2003 by the Education Working Group of the Consortium of Academic Health Centers for Integrative Medicine (CAHCIM) and endorsed by the CAHCIM Steering Committee in May 2003. CAHCIM is a consortium of 23 academic health centers working together to help transform health care through rigorous scientific studies, new models of clinical care, and innovative educational programs that integrate biomedicine, the complexity of human beings, the intrinsic nature of healing, and the rich diversity of therapeutic systems. Integrative medicine can be defined as an approach to the practice of medicine that makes use of the best-available evidence taking into account the whole person (body, mind, and spirit), including all aspects of lifestyle. It emphasizes the therapeutic relationship and makes use of both conventional and complementary/alternative approaches. The competencies described in this article delineate the values, knowledge, attitudes, and skills that CAHCIM believes are fundamental to the field of integrative medicine. Many of these competencies reaffirm humanistic values inherent to the practice of all medical specialties, while others are more specifically relevant to the delivery of the integrative approach to medical care, including the most commonly used complementary/alternative medicine modalities, and the legal, ethical, regulatory, and political influences on the practice of integrative medicine. The authors also discuss the specific challenges likely to face medical educators in implementing and evaluating these competencies, and provide specific examples of implementation and evaluation strategies that have been found to be successful at a variety of CAHCIM schools.

Mind-body therapies for the management of pain

This paper reviews the evidence for mind-body therapies (eg, relaxation, meditation, imagery, cognitive-behavioral therapy) in the treatment of pain-related medical conditions and suggests directions for future research in these areas. Based on evidence from randomized controlled trials and in many cases, systematic reviews of the literature, the following recommendations can be made: 1) multi-component mind-body approaches that include some combination of stress management, coping skills training, cognitive restructuring and relaxation therapy may be an appropriate adjunctive treatment for chronic low back pain; 2) multimodal mind-body approaches such as cognitive-behavioral therapy, particularly when combined with an educational/informational component, can be an effective adjunct in the management of rheumatoid and osteoarthritis; 3) relaxation and thermal biofeedback may be considered as a treatment for recurrent migraine while relaxation and muscle biofeedback can be an effective adjunct or stand alone therapy for recurrent tension headache; 4) an array of mind-body therapies (eg, imagery, hypnosis, relaxation) when employed pre-surgically, can improve recovery time and reduce pain following surgical procedures; 5) mind-body approaches may be considered as adjunctive therapies to help ameliorate pain during invasive medical procedures.

Realizing Engel's vision: psychosomatic medicine and the education of physician-healers

Many of the exciting conceptual and scientific advances in the field of psychosomatic medicine are not taught in United States medical schools. This article, based on the Presidential Address given at the Annual Meeting of the American Psychosomatic Society in Phoenix, Arizona in March 2003, reviews the rationale for integrating psychosomatic medicine into medical curricula, identifies educational needs, proposes a core curriculum, and suggests how American Psychosomatic Society members can be instrumental in curriculum development and implementation.

Integrative medical education: development and implementation of a comprehensive curriculum at the University of Arizona

Dissatisfaction with the U.S. health care system is increasing despite impressive technologic advances. This dissatisfaction is one factor that has led patients to seek out complementary and alternative medicine (CAM) and led medical schools to start teaching CAM. This paper focuses on the University of Arizona's approach to developing and implementing a comprehensive curriculum in integrative medicine. Integrative medicine is defined much more broadly than CAM. It is healing-oriented medicine that reemphasizes the relationship between patient and physician, and integrates the best of complementary and alternative medicine with the best of conventional medicine. Since its inception in 1996, the Program in Integrative Medicine (PIM) has grown to include a two-year residential fellowship that educates four fellows each year, a distance learning associate fellowship that educates 50 physicians each year, medical student and resident rotations, continuing medical and professional education, an NIH-supported research department, and an active outreach program to facilitate the international development of integrative medicine. The paper describes the PIM curriculum, educational programs, clinical education, goals, and results. Future strategies for assessing competency and credentialing professionals are suggested.