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Teaching Psychosomatic (Biopsychosocial) Medicine in United States Medical Schools: Survey Findings

From the Department of Psychology, University of Maryland, Baltimore County; Division of Gerontology, Department of Medicine, University of Maryland School of Medicine; and Geriatrics Research Education and Clinical Center, Baltimore Veterans Affairs Medical Center (S.R.W., S.A.N.), Baltimore, Maryland; the Division of Digestive Diseases and Nutrition, University of North Carolina (D.A.D.), Chapel Hill, North Carolina; and the Office of Educational Affairs, MCP Hahnemann School of Medicine (D.H.N.), Philadelphia, Pennsylvania.

Address reprint requests to: Shari R. Waldstein, PhD, Department of Psychology, University of Maryland, Baltimore County, 1000 Hilltop Circle, Baltimore, MD 21250. Email: waldstei{at}umbc.edu

	ABSTRACT

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSION NOTES ACKNOWLEDGMENTS REFERENCES

 
OBJECTIVE: A survey of US medical schools regarding the incorporation of psychosomatic (biopsychosocial) medicine topics into medical school curriculum was conducted. The perceived importance and success of this curriculum, barriers to teaching psychosomatic medicine, and curricular needs were also assessed.

METHODS: From August 1997 to August 1999, representatives of US medical schools were contacted to complete a survey instrument either by telephone interview or by written questionnaire.

RESULTS: Survey responses were received from 54 of the 118 US medical schools contacted (46%). Responses were obtained from representatives of both public (57%) and private (43%) institutions. Only 20% of respondents indicated that their schools used the term "psychosomatic medicine"; the terms "behavioral medicine" (63%) and "biopsychosocial medicine" (41%) were used more frequently. Coverage of various health habits (eg, substance use and exercise) ranged from 52% to 96%. The conceptualization and/or measurement of psychosocial factors (eg, stress and social support) was taught by 80% to 93% of schools. Teaching about the role of psychosocial factors in specific disease states or syndromes ranged from 33% (renal disease) to 83% (cardiovascular disease). Coverage of treatment-related issues ranged from 44% (relaxation/biofeedback) to 98% (doctor-patient communication). Topics in psychosomatic medicine were estimated to comprise approximately 10% (median response) of the medical school curriculum. On a scale of 1 (lowest) to 10 (highest), ratings of the relative importance of this curriculum averaged 7 (SD = 2.5; range = 2–10). Student response to the curriculum varied from positive to mixed to negative. Perceived barriers to teaching psychosomatic medicine included limited resources (eg, time, money, and faculty), student and faculty resistance, and a lack of continuity among courses. Sixty-three percent of respondents expressed an interest in receiving information about further incorporation of topics in psychosomatic medicine into their school’s curriculum.

CONCLUSIONS: Results of this survey reveal variable coverage of specific psychosomatic medicine topics in the medical school curriculum and differential use of nomenclature to refer to this field. There is a need for further curricular development in psychosomatic medicine in US medical schools.

Key Words: psychosomatic medicine • biopsychosocial medicine • biopsychosocial model • medical education • medical curriculum • survey.

Abbreviations: APS = American Psychosomatic Society; HIV = human immunodeficiency virus.

	INTRODUCTION

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSION NOTES ACKNOWLEDGMENTS REFERENCES

 
In 1977 George Engel argued that medical education and practice were based on an outdated reductionist and exclusionist biomedical model that limited physicians’ understanding of illness (1). He described an alternative biopsychosocial model that recognized the essential unity of mind and body. Physicians trained in this model would include biological, psychological, and social factors in their scientific understanding of disease pathogenesis and pathophysiology and in the treatment of illness. Acquisition of a biopsychosocial knowledge base would facilitate an understanding, from the molecular to the societal levels, of how diverse factors such as stressful events, hope, grief, and social support could contribute to patients’ illness (and their experience of illness). Combining knowledge of behavioral medicine and psychology with biomedicine would allow physicians to offer more comprehensive and holistic treatment of patients. Engel challenged medical educators to alter their curricula to teach medicine from this biopsychosocial perspective.

Engel’s insights derived, in part, from years of contributing to psychosomatic medicine, a field that is predicated on a biopsychosocial model. Since 1942 the APS, of which Engel was president in 1953, has been an academic society of researchers, educators, and practitioners interested in mind-body interactions. The APS (and the field of psychosomatic medicine) broadly dedicates its mission to "the integration of biological, psychological, and social factors in medicine"; its annual meetings are forums for presentation of diverse basic and clinical research that broadens our understanding of health and illness within a biopsychosocial perspective.

It has become apparent that findings from the field of psychosomatic medicine are of critical importance to medical research and practice. For example, it is clear that biological risk factors for both acute and chronic illnesses account for only part of the variance in disease outcomes. Psychosocial factors have been demonstrated to influence the etiology, pathophysiology, and/or treatment of numerous chronic diseases such as cardiovascular disease (2), cancer (3), and gastrointestinal diseases (4); the acquisition and/or progression of infectious diseases (5) and HIV (6); and the efficiency of postsurgical recovery (7). Research in psychosomatic medicine has also identified predictors of nonadherence (8), a problem that can be highly disruptive of optimal patient care.

The American Association of Medical Colleges has called for improved biopsychosocial education (9), and some progress has been made in this area (10). However, there is evidence that much remains to be accomplished to adequately meet Engel’s challenge (11, 12). Accordingly, the purpose of the present survey was to assess the incorporation of topics in psychosomatic (biopsychosocial) medicine into the curriculum of US medical schools, the perceived success of this curriculum, barriers to teaching these topics, and curricular needs.

	METHODS

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSION NOTES ACKNOWLEDGMENTS REFERENCES

 
The mission of the APS includes improvement of biopsychosocial education in medical schools. Therefore, its Professional Education Committee was commissioned to undertake a survey of US medical schools to assess their curricular needs and to recommend how the APS might respond to those needs. Financial support was provided by the APS to sponsor development of a survey instrument and study implementation by members of the Professional Education Committee.

From August 1997 to August 1999, representatives of 118 US medical schools listed in the 42nd edition of the Directory of American Medical Education were contacted about participating in this survey.¹ The survey questionnaire was developed by the authors and was reviewed for feedback by nine colleagues with expertise in teaching psychosomatic medicine in medical settings and/or survey methodology. The final five-page survey questionnaire took approximately 15 to 20 minutes to complete, either by telephone interview or in written form. Two questions were added after review of the first 10 completed interviews. Copies of the survey instrument can be obtained from the authors (S.R.W. or D.H.N).

To contact medical school representatives, one of the authors (S.A.N.) first placed a call to the office of the Dean of Medical Education (or related office), identified herself as a representative of the APS, briefly described the purpose of the survey, and asked to be referred to an appropriate respondent. That individual was contacted and asked to participate in either a telephone interview or to complete a faxed version of the survey. Nonresponses to faxed surveys were followed up with reminder calls.

To equate the term "psychosomatic medicine" with a biopsychosocial approach to research, teaching, and practice, administration of the survey began with provision of a working definition of psychosomatic medicine that was taken from the mission statement of the APS: "Psychosomatic medicine is concerned with the interrelationships among biological, psychological, social, and behavioral factors in human health and disease, the integration of the fields of science that separately examine each, and the application of this understanding in education and improved health care." It was acknowledged that schools likely use different terminology to refer to this field of study, and the respondent was asked to identify the terms used in their medical school setting by examining a checklist of items and endorsing all applicable terms (and providing any additional terms).

Respondents were then asked whether their medical school curriculum included coverage of specific topics in psychosomatic medicine in the following categories: 1) health habits; 2) psychosocial factors (conceptualization and/or measurement); 3) the role of psychosocial influences in disease pathogenesis, psychophysiology/mechanism, and behavioral treatments; and 4) treatment (interventions, outcomes, and influences). Respondents were instructed to endorse a specific topic only if the teaching "included information on the interrelationships among biological, psychological, social, and behavioral factors" (ie, a biopsychosocial approach). Additional questions inquired about the types of courses in which these topics were taught and the disciplines of the instructors. The respondents were asked to provide a rough estimate of the extent of coverage, throughout the medical school curriculum, of the specific topics that they had endorsed, and to indicate the percentage of the entire medical school curriculum that these topics comprised. Questions also inquired about the structure and coordination of this curriculum and the use of didactic materials.

Ratings were obtained, using a scale of 1 (lowest) to 10 (highest), regarding the perceived importance of psychosomatic medicine in the medical school curriculum. Respondents were asked about their perception of the medical students’ reactions to the curriculum related to psychosomatic medicine, the current needs and interests of their school with respect to topics in psychosomatic medicine, and any perceived barriers to teaching these topics. They were also asked whether curricular assistance would be helpful and, if so, to specify the nature of that assistance (eg, audiovisual materials).

Of the 118 US medical schools contacted, 54 (46%) completed the survey; 63% of these were written surveys returned by fax or mail, and 37% were completed by telephone interview. Forty-one percent of the surveys were completed by a representative from the office of the Dean of Medical Education or a related office (eg, Academic Affairs, Curricular Affairs, or Academic Programs) and included deans, associate deans, assistant deans, executive assistants to the dean, and administrative directors of the dean’s office. Another 20% were completed by a curriculum manager, coordinator, or director; 20% by a psychiatrist; 13% by a behavioral medicine or behavioral science representative; and 6% by a professor from another discipline. Of the 64 (54%) nonrespondents, only 10 directly declined to participate in the study. The other 54 initially agreed to participate but did not return their faxed surveys.

As depicted in Table 1, the responding and nonresponding schools did not differ in terms of type of institution (public vs. private), average enrollment, or average year during which the school was founded. Geographic regions were represented similarly with two exceptions: there were significantly more nonrespondents than respondents from the North Central region (² = 4.17(1), p < . 05); there was also a trend toward more respondents than nonrespondents from the Northeast region (² = 2.78(1), p < .10).

	RESULTS

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSION NOTES ACKNOWLEDGMENTS REFERENCES

Psychosocial Factors (Conceptualization and/or Measurement)
The majority of respondents (80–93%) indicated that their schools teach about issues related to the conceptualization and/or measurement of psychosocial factors such as personality (eg, Type A behavior pattern, anger/hostility, depression, and anxiety), stress, somatoform disorders or somatization, and social support/coping (see Table 4).

Role of Psychosocial Influences on Disease Pathogenesis, Psychophysiology/Mechanism, and Behavioral Treatments
Sixty-three to eighty-three percent of respondents reported that their schools taught about biopsychosocial factors in relation to cardiovascular disease, chronic pain, HIV/AIDS, cancer, gastrointestinal disorders, and psychoneuroimmunology (see Table 5). However, relatively fewer schools (33–56%) taught about biopsychosocial factors in relation to headaches, diabetes mellitus, and infectious, autoimmune, pulmonary, and renal diseases.

Treatment: Interventions, Outcomes, and Influences
The majority of respondents (63–98%) endorsed coverage of topics such as doctor-patient communication, psychological therapies, treatment adherence/compliance, stress management, genetic counseling, and stages of behavior change (transtheoretical model of change), with only approximately half (44–54%) covering quality of life or relaxation/biofeedback (see Table 6).

Types of Courses and Structure of Curriculum
Respondents indicated that the topics in psychosomatic medicine they had endorsed in the above categories were either covered in required courses (85%) or in both required courses and electives (15%). The format of these courses were mainly lecture (96%) or seminar (89%), but also included clinical settings and rounds (66%), assigned readings (62%), and independent study (23%). Most respondents provided numerous examples of the specific courses in which the medical students would learn about psychosomatic medicine topics. Common examples of these courses included Behavioral Science, Human Behavior, Clinical Skills/Clinical Medicine, Psychopathology, Family Medicine, Preventive Medicine, Internal Medicine, Human Development, and Health Promotion. The disciplines of the course instructors included psychiatry (98%), internal medicine (79%), family medicine (70%), psychology (60%), pediatrics (40%), epidemiology (40%), public health (38%), obstetrics/gynecology (32%), social work (30%), physiology (28%), and sociology (6%).

Extent of Topic Coverage and Structure of Curriculum
When asked to provide a rough estimate of the extent of coverage, throughout the medical school curriculum, of the topics that had been endorsed, 39% indicated that more than 40 hours of coverage was provided throughout the curriculum, 30% reported 24 to 40 hours, 16% indicated 8 to 24 hours, 2% reported less than 8 hours of coverage, 11% stated that they did not know, and 2% indicated that it varied as a function of student interest. Responses to the question "approximately what percent of the entire four year medical school curriculum does this coverage of topics amount to?" ranged from 1% to 60% (the majority of estimates were <30%). The mean response was 14%, and the median response was 10%. However, 32% of those asked were unable to provide a response.²

Thirty-seven percent of respondents indicated that their school had a written curriculum for psychosomatic medicine, and 39% had an individual who coordinated this type of curriculum. Twenty-five percent reported using a textbook. Examples given included Behavior and Medicine and Behavioral Medicine in Primary Care. Eighteen percent used journal articles for assigned readings. Journals included Health Psychology, Psychosomatic Medicine, Annals of Behavioral Medicine, Psychosomatics, and Journal of the American Medical Association.

Perceived Importance of Curriculum and Student Reaction
Respondents rated, on a scale of 1 (lowest) to 10 (highest), the importance of psychosomatic medicine in the medical school curriculum. Both the mean and median ratings were 7 (SD = 2.5; range = 2–10). Sixty percent of responses to the open-ended question "What do you perceive to be the student reaction to the curriculum related to psychosomatic medicine?" were generally positive. Comments included "very positive," "very enthusiastic," "high interest," and "the students appear to recognize the importance of this material for the practice of medicine."

Twenty percent of the comments were negative. Comments included "not taken as seriously," "skepticism and some impatience," "other things are more important," "most concentrate on hard sciences," "they consider this a soft science," "the students find it difficult to comprehend the connections," and "many students don’t recognize the importance of this material until their clerkships or residency."

Twenty percent of the responses were mixed, and comments included "receptive in varying degrees" and "one-third are really interested while the majority are middle ground," "one-third positive, one-third negative, and one-third moderate reactions," "average reaction is modest enthusiasm," and "students who come from a behavioral science background generally seemed more interested in this type of curriculum."

Perceived Needs
Numerous responses were given to the open-ended question "In your opinion, what do you perceive to be the current needs and interests of your school in the(se) topic areas...?" Examples of comments reflected a desire to "enlighten and educate faculty," suggestions to "use more small group and clinical case–based teaching" and "experiential learning for students," a need for "peer-reviewed literature and resources relevant to clinical treatment and patient care," "materials to give good examples of application," and "tapes, slides, videos, lecture materials." Also suggested was "developing assessment measures for student competency in this area" and "help students appreciate the relevance of behavior." Several respondents suggested providing training programs for medical school faculty to teach them relevant material and, perhaps more importantly, "to teach them how to teach psychosomatic medicine."

Perceived Barriers
When asked "Are there any barriers to teaching these topics? Please specify.," the responses generally reflected issues regarding limited resources such as lack of time, money, and available faculty; resistance from faculty and students; and a lack of continuity among courses. Several specific comments included observations about "old-school thinking" and "students don’t take it seriously." The teaching "works better in small groups, but the student population is too big"; "faculty priorities and facilities are limited", "a need for more integration of this material across courses"; "a need for faculty role models"; "support from the dean’s office", "more faculty, more time, more money"; "making it a higher priority"; and "lack of time."

Curricular Assistance
Sixty-three percent of respondents indicated that they would like curricular assistance in relation to psychosomatic medicine topics. More specifically, information that was found to be potentially helpful included audiovisual materials (29%), reference materials (27%), actual lecture materials (21%), and a listing of books (19%). Seventeen percent thought that anything would be helpful. Others indicated a need for clinical vignettes or case examples.

	DISCUSSION

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSION NOTES ACKNOWLEDGMENTS REFERENCES

 
Results of this survey reveal variable coverage of topics in psychosomatic medicine in US medical schools and generally suggest deficiencies in biopsychosocial curricula. In this regard, coverage of specific psychosomatic medicine subtopics ranged from 33% to 98%, and it was estimated that biopsychosocial teaching most commonly comprised approximately 10% of the total medical school curriculum. Given that approximately 7000 to 8000 hours are dedicated to the undergraduate medical curriculum, it is striking to note that almost 50% of schools endorsed less than 40 hours of total instruction in psychosomatic medicine. It is also possible that this survey overestimated biopsychosocial teaching in US medical schools in that our respondents may have been more inclined toward a positive view of such teaching than our nonrespondents.

Because of the importance of psychosomatic medicine to a comprehensive understanding of health and disease and to holistic patient care, and given an increased interest in expanding primary care and patient-centered medicine, such limited biopsychosocial instruction in undergraduate medical education is likely to be inadequate. Such curricular deficiencies may, in part, contribute to ongoing problems with medical care in the US. For example, the fact that many patients visit alternative medicine practitioners suggests that their needs are not being met sufficiently by their physicians (13), and key predictors of patient satisfaction remain unclear (14, 15). In addition, primary care has been called the "de facto mental health system" in the US (16), yet physicians continue to underdiagnose and undertreat major mental health problems such as anxiety and depression.

Further incorporation of topics in psychosomatic medicine into medical education may prove particularly useful in terms of improving patient satisfaction through promotion of holistic health care. However, the present survey findings, discussed below, indicate a need to overcome barriers to the further inclusion of biopsychosocial perspectives in the medical school curriculum.

Nomenclature
Survey results indicate that the term "psychosomatic medicine" is unfamiliar nomenclature in the majority of US medical schools, with "behavioral medicine" and "biopsychosocial medicine" being more commonly used. It is possible that use of common nomenclature would facilitate communication regarding a biopsychosocial curriculum.

Coverage of Subtopics
Although many topics in psychosomatic medicine are receiving some coverage in medical school curricula, the teaching of specific subtopics from a biopsychosocial perspective is quite variable. These survey findings therefore suggest particular areas of the biopsychosocial curriculum that require increased attention.

With respect to the variable biopsychosocial coverage of issues related to health habits such as exercise, weight control, and substance use (52–96%), more intensive instruction is necessary, particularly from the perspectives of improved primary (and secondary) prevention of chronic disease, chronic disease management, and for general health promotion. It has been demonstrated that counseling skills pertinent to nutrition, smoking cessation, and other risk factors can be taught effectively in medical education (17–19). However, prior survey work suggests that less than one-third of schools use active teaching techniques such as faculty observation or role play to teach such clinical skills, and fewer than 2 curricular hours are dedicated to the teaching of preventive counseling skills (10).

Next, further teaching about the conceptualization and measurement of psychosocial factors such as stress, social support, coping, and personality factors can provide a critical basis for understanding the role of such factors in health and disease, for the screening of relevant factors in individual patients (eg, depression, hostility, and social support), and the consideration of such personal characteristics in patient diagnosis, treatment, and adherence issues. Biopsychosocial teaching about the role of such factors in disease pathogenesis and associated discussion of potential underlying mechanisms and behavioral treatments also requires enhancement. In this regard, whereas many programs provide some instruction regarding biopsychosocial influences in cardiovascular disease, chronic pain, HIV/AIDS, and cancer (67–83%), numerous other diseases or chronic conditions, such as headaches, diabetes mellitus, and infectious and renal disease, receive limited coverage (33–56%).

Biopsychosocial perspectives on treatment-related issues were also variable, and it is particularly striking that important concepts such as quality of life received coverage by only approximately half of the surveyed schools. Understanding such material is critical to treatment adherence and patient satisfaction. Furthermore, knowledge of various psychological therapies and models of behavior change can enhance standard medical practice, particularly with respect to the management of chronic diseases and conditions (eg, chronic pain) and the promotion of treatment adherence and good health behaviors.

Extent of Coverage and Curricular Organization
The degree of coverage that is actually received by the subtopics assessed by this survey remains unknown and difficult to assess. Respondents had difficulty providing estimates of extent of topic coverage, in part because it is spread diffusely throughout the curriculum. It is therefore impossible to determine which topics receive cursory vs. extensive attention. Indeed, it is apparent that topics in psychosomatic medicine are covered in numerous courses that are taught by persons of various disciplines, but mainly psychiatry, internal medicine or family medicine, and psychology. Our data suggest that physiology courses are not major contributors to teaching the basic psychophysiology (eg, mechanisms) that can underlie mind-body interactions. Indeed, major medical school physiology texts do not offer an organized or comprehensive approach to psychophysiology.

It is also impossible to comment on teaching quality. However, our prior survey on clinical skills teaching shows that there is little in the way of written goals and objectives, evaluation, and faculty development (10). In addition, few schools reported having a formalized, written curriculum in psychosomatic medicine, and the majority of schools did not have an individual to coordinate the biopsychosocial curriculum. Even fewer reported using any particular books or articles for didactic purposes. This may, in part, reflect the fact that there is no single, comprehensive text that covers the full range of topics in psychosomatic medicine.

Because psychosomatic medicine is both a basic and applied multidisciplinary science, it is appropriate that topic coverage should appear throughout the curriculum in diverse courses such as physiology, behavioral science, clinical sciences, and neuroscience. However, specific coursework in psychosomatic medicine could also be useful. Indeed, a number of US medical schools offer courses that combine or coordinate teaching of behavioral sciences, doctor-patient communication, and medical ethics (9). However, it seems that most US medical schools do not have a longitudinal, comprehensive approach to teaching psychosomatic medicine.

Response to Curriculum: Perceived Importance and Barriers
On average, survey respondents indicated that psychosomatic medicine was viewed as an important part of medical education, although the range of rated importance reveals some variability in perspective. In addition, the majority of open-ended comments indicated that medical students have positive views of this type of curriculum. However, there were also quite a few mixed or negative responses. In this regard, it is critical to note that there were numerous perceived barriers to the further incorporation of psychosomatic medicine into medical school curricula.

Many of the specific barriers identified by our respondents (eg, limited resources such as lack of time, money, and available faculty; resistance from faculty and students; and a lack of continuity among courses) have also been noted in prior survey work by Novack et al. (20), who assessed the teaching of medical interviewing and interpersonal skills in US medical schools. For example, there is clear competition among disciplines for curricular time. Overcoming these barriers may require an increase in resources and enhanced support by administrators, faculty, and students. It may also require change in attitudes about the perceived importance of a biopsychosocial model in medical education and health care. Successful implementation of further curricular emphasis in psychosomatic medicine would likely benefit from active support of the office of the Dean of Medical Education, with reinforcement of a biopsychosocial emphasis among faculty, and faculty reinforcement of this emphasis among students. Further efforts in faculty development are also necessary to train instructors, particularly those in the basic sciences, about biopsychosocial medicine. There are also a variety of other influences (eg, reimbursement issues and stigma) that may present challenges to the biopsychosocial education of physicians (21, 22) and that will need to be addressed as part of any efforts in curricular reorganization.

Curricular Assistance
Shrinking resources make it difficult to address the identified barriers of time and money. It may therefore be particularly important for outside sources, such as the APS, to assist by providing tangible materials, training suggestions, or actual training regarding psychosomatic medicine curriculum. In this regard, many survey respondents indicated that they would appreciate curricular assistance with respect to teaching psychosomatic medicine. Some noted that particular types of information, such as audiovisual, reference, or lecture materials or provision of case examples, would be useful. Information packets that include a suggested curriculum and specific teaching materials could be developed for distribution to medical schools.

In this regard, the Association for Behavioral Sciences in Medical Education has published a Behavioral Science Curriculum Guide (23) that includes many topic areas relevant to psychosomatic medicine. In addition, the APS is currently sponsoring a project to make psychosomatic medicine teaching aids in targeted topic areas available to medical schools. Medical schools can also take advantage of the APS Visiting Scholars Program, which yearly awards up to six visiting scholars to US medical schools, to aid in faculty development. The Office of Behavioral and Social Sciences Research at the National Institutes of Health and other agencies might consider making increased funds available for studying the effectiveness of relevant educational interventions on student learning and attitude and behavior change. The National Board of Medical Education should also consider adding more questions in basic sciences related to psychosomatic medicine to the US Medical Licensing Examination. This would likely induce schools to improve their curricula. In addition, the National Board of Medical Education is in the process of developing a standardized clinical skills assessment for potential inclusion in the licensing examination (24). Topics in psychosomatic medicine could also be incorporated into this portion of the evaluation. Finally, curriculum committees could appoint subcommittees to oversee coordination and development of biopsychosocial curriculum.

Study Limitations
An important limitation of the present survey study is the limited response rate of 46%. This figure is similar to the mean response rate of 54% noted in a recent review of surveys of physicians that were published in medical journals (25) and suggests a general difficulty in obtaining responses to survey materials. In addition, although the responding and nonresponding institutions were comparable with respect to virtually all descriptive characteristics, the respondents and nonrespondents may have differed in their attitudes toward psychosomatic medicine. As noted above, it is possible that our findings overestimate the incorporation of psychosomatic medicine in medical education. Overreporting of coverage may have also occurred as a result of a social desirability bias.

Next, it is unlikely that each respondent was fully aware of all educational activities related to psychosomatic medicine in their respective institutions. Thus, as noted earlier, the precise degree of coverage of biopsychosocial material is difficult to assess. In addition, survey responses may have been influenced by differential understanding of the terms "psychosomatic medicine" and "biopsychosocial model." Although we tried to largely equate these terms for survey respondents, it is likely that individuals had differing interpretations.

Finally, the present survey did not include osteopathic schools. Such schools may have an even greater focus on training in psychosomatic medicine and should be included in future research.

	CONCLUSION

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSION NOTES ACKNOWLEDGMENTS REFERENCES

 
Further incorporation of psychosomatic medicine in US medical school curricula is critical to the continued transition of the medical field from a traditional biomedical model toward a biopsychosocial model with an increased emphasis on prevention and holistic evaluation and treatment of individuals. A biopsychosocial model can offer a scientific approach to the "art of medicine" by emphasizing the importance of communication and the systematic consideration of psychosocial factors pertinent to patients’ health status. Indeed, psychosomatic medicine could be considered the basic and clinical science of healing.

	ACKNOWLEDGMENTS

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSION NOTES ACKNOWLEDGMENTS REFERENCES

 
This study was supported by the American Psychosomatic Society and the University of Maryland, Baltimore County, Designated Research Initiative Fund. The authors gratefully acknowledge the assistance of the following colleagues, who provided helpful feedback on earlier versions of the survey instrument: Drs. Margaret Chesney, Bruce DeForge, Carlo DiClemente, Joel Dimsdale, Ann Maxwell Eward, Donald Kornfeld, Herbert Ochitill, Donald Oken, and Edward Pecukonis. We also thank Laura Degnon and Aarti Shastry for their assistance in administering this study. Thanks are also extended to Herb Ochitill for his helpful comments on an earlier version of this manuscript.

	NOTES

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSION NOTES ACKNOWLEDGMENTS REFERENCES

 
One hundred twenty-one schools were listed in this directory. However, representatives of three schools (in Illinois, Missouri, and Hawaii) could not be contacted.

The first 10 surveys asked respondents to indicate what amount of coverage, in hours, was received by each specific topic in psychosomatic medicine that they had endorsed. Because the respondents were generally unable to provide such estimates, the prompts were eliminated and these two more general questions regarding estimation of extent of coverage of topics in psychosomatic medicine in the medical school curriculum were added to the survey instrument.

Received for publication August 14, 2000.

	REFERENCES

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSION NOTES ACKNOWLEDGMENTS REFERENCES

 

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