Concluding Commentary: Teaching Social and Behavioural Sciences in Medical Education

We were delighted that the editorial team of MedEd Publish were keen to have 'Teaching Social and Behavioural Sciences (SBS) in Medical Education' as a themed issue. As we highlighted in our opening editorial (Harden, Kendall and Macbride-Stewart) there is increasing awareness of the significance of SBS in understanding health, illness and disease and so an expectation that SBS is included within medical curricula. Submission to the themed issue ran from October – December 2016 and we received 15 papers which included review articles (3), personal opinion commentaries (6), case studies (3), description of new educational methods/tools (2); and practical tips (1), with authors representing experiences from 8 different countries. It was fascinating reading both the papers themselves and the reviews from other contributors. It is clear that there is not only interest in this area but a thirst for some dialogue to share experiences and make progress in addressing some key challenges. In this concluding commentary, we offer some reflections on the themes raised within the issue. Social and behavioural sciences as 'need to know' subjects for medical education There was, perhaps unsurprisingly, clear agreement of SBS as 'need to know' rather than simply 'nice to know'. The papers contributed many examples within different academic and cultural contexts to support this. Amaral Mendes reinforced the global significance of social determinants of health, towards Abstract Keywords: Social and Behavioural Sciences Article Background

an understanding of which SBS play a fundamental role. Several papers commented on the complexity involved in health, illness and disease and the key role that SBS has to play in understanding that complexity. A specific example of this was given by Rebelo Hopkins and Turner who highlighted the centrality of social and ethical understandings of genomics to students' learning. The requirement of medical schools to produce graduates who are socially responsible was also given as the context and in some cases the driver for the inclusion of SBS within the curriculum; SBS was noted as playing a key role in addressing this goal (McMillan, Orsmond and Zvauya; Van Deven et al). Iida and Nishigori highlighted the role that SBS can play in developing clinical skills in their review of physical examination and the physician-patient relationship. Despite potential cultural and educational differences, across all these papers, there was much common ground. This was also reflected in the paper by Chan, Harden and Salas which discussed a workshop comparing experiences of ethics and social science teaching in medicine in Chile and Scotland; they reported considerable concordance in the perceived need for the inclusion of these subjects in the curriculum.

Opportunities and examples of good practice
The papers in the themed issue also highlighted many opportunities for SBS within medicine and provided examples of good practice. For example Corrigan et al. noted the role to be played by learning technology in facilitating students' SBS learning. This was demonstrated in two papers that discussed the use of patient videos as a method to enhance students' awareness and understanding of patients' experiences and of the complexity within those experiences (Boose Pinheiro et al.; Nanna, Tackett and Gaglani). Collett, Brooks and Forrest in their literature review presented the move towards integrated curricula as an opportunity for SBS and this was reflected in the discussion of integration as a key trend within many of the papers. McMillan, Orsmond and Zvauya outlined the success of an integrated curriculum for graduate-entry medical students that drew together biological and SBS subjects and staff. Whittaker and Williams discussed the positive results arising from the integration of a public health course within the clinical curriculum. Van Deven et al. presented an outline of an integrated social medicine course intended to facilitate 'deeper student learning.' These papers also emphasised the benefits of interdisciplinary teams working together towards integration. Indeed Corrigan et al. discussed interdisciplinarity as being at the core of their 'identity as medical educators'. There are clearly many positive expectations and experiences arising from the opportunities that the integration of SBS subjects with clinical and basic sciences in medical curricula can offer. Challenges Nevertheless, integration is not a straightforward 'solution' to the challenges relating to SBS in medical education that have been documented in this themed issued and elsewhere. The overall aim of integration is typically stated as improving or deepening students' knowledge and understanding. However, as we comment in some of our reviews, it is not always clear what forms of integration have been considered; what evidence base is drawn from in making that decision; what the criteria for success are; and how that success will be measured. The model adopted to integrate SBS into the curriculum and how well it is implemented are central issues to consider. Razzai's paper questioned the potential negative impact of simulated patients if the case being presented appears to reinforce stereotypes. We saw this as a clear example of the problems arising when SBS-related topics, in this case equality and diversity, are integrated into the curriculum but are not scaffolded by a broader understanding of and critical engagement with relevant issues. This also relates to questions of expertise. As noted above, several papers highlighted the benefits of Harden J, Kendall K, MacBride-Stewart S MedEdPublish http://dx.doi.org/10.15694/mep.2016.000166 interdisciplinarity in developing and delivering integrated curricula. Yet, there remain questions about who is best placed to teach SBS subjects, at what points, on what basis and what the implications may be. Whittaker and Williams commented that their public health course may have been perceived by students as less relevant because it was taught by non-clinicians. The obvious response to this may be to use clinical tutors. However, we could also ask why the students have this perception. Does the course lack relevance or do the students assume that clinical teachers will always be more 'relevant'? If it is the latter then it may be the students' perception that needs to be addressed rather than the staff delivering the teaching. Collett, Brooks and Forrest highlight this concern noting that while there may be more time allocated to SBS in the curriculum this time may be divided across many courses delivered by a range of staff (clinical and non-clinical) with differing knowledge, experience and ways of presenting, applying and evidencing SBS topics. Without a high level of coordination and oversight it is likely that there will be inconsistencies, repetition, and potential contradictions. We cannot assume therefore that the integration of SBS in itself will lead to deeper learning by the students. The significance of SBS as 'other', as representing an epistemological position that differs from medicine was also presented as a challenge to integration (Neville and Waylen). Khan's paper on social medicine in the Arab world highlighted the concerns that SBS would open discussion of issues that were considered culturally to be private and so not appropriate within the curriculum. Some papers noted that it is through the 'hidden curriculum' that the difference between biomedicine and SBS becomes significant. This disparity is evident, for example where there are negative attitudes towards SBS among staff that are then transmitted to students (McMillan, Orsmond and Zvauya), or where the leadership is very biomedically oriented and act as a barrier to SBS integration via resource allocation (Brooks, Collett and Forrest). While these concerns clearly still resonate for some of those involved in SBS teaching, we also had insight from the papers of positive experiences of interdisciplinary working. Moreover, as Brooks, Collett and Forrest highlight there is increasing awareness of and interest in alternative socially-oriented paradigms within medicine that may lessen potential divides. In a recent visit to Chile, Jeni Harden was inspired by the work of one of the new medical schools whose Vice Rector and Dean of the Medical Faculty were not only supportive of SBS but were also instrumental in driving forward a programme with SBS at its core. As Corrigan et al. point out, we are all on an 'epistemological journey' as we work towards developing collaborative integrated curricula. Moreover, many of the papers cited, particularly by the review articles, are based on research conducted nearly a decade or more ago. This may serve to reinforce the sense that these issues are intractable but also points to the need for more research.
The issues raised in the papers that we have highlighted here have been discussed for many years and in many different countries (and educational contexts) across the world. We have a good understanding of the facilitators and barriers towards SBS integration. What remains unclear is whether we are slowly evolving towards curricula that integrate SBS more effectively or whether the challenges faced decades ago remain relatively intact. It may be that working within current curricular and programme systems to enhance integration will have a significant impact over time. Equally, we could question whether we need to adopt a more 'revolutionary' approach? It may well be that as Harden (2000) pointed out, "simply improving the existing system may not be sufficient… New ways of thinking about medical education are called for. We need a new mindset" (p441). What that 'mindset' would be in relation to the role that SBS plays in medical education is one that we should tackle head on. If we could start from Harden J, Kendall K, MacBride-Stewart S MedEdPublish http://dx.doi.org/10.15694/mep.2016.000166 Moving forward • • scratch as the pioneers of medical education, what would we do? To help answer this we need to work together.

Building a community of practice
The papers included in this themed issue raise many questions, both specific to each paper or the experience being discussed, but also in a broader sense, relating to SBS in medical education. We would like to see the special issue as a starting point that will encourage further discussions. We would encourage contributors to the issue, as well as those who have read the papers, to work with us in building an international community of practice to share ideas and resources and establish collaborations. There are a number of platforms that we already have that we can use to do this: BeSST (Behavioural and Social Science Teaching in Medicine) is a network for those interested or working in SBS in medicine so if you have not already done so, please have a look at the website and consider joining. You can also find the Core Curriculum for Sociology in UK Undergraduate Medical Education' on this website'. We encourage people to share resources via the website (www.besst.info). If you have anything you would like to share please let us know.
We also coordinate a Special Interest Group (SIG) on MedEdWorld (http://www.mededworld.org/SIGs.aspx?forumid=558) where we encourage people to post comments or ask questions.
It would be fantastic if we can keep up the momentum generated by this themed issue of MedEdPublish, to develop a dynamic and productive community of practice. We would like to thank all of the theme contributors and look forward to future conversations. Dr Jeni Harden is Director of Education in the Usher Institute of Population Health Sciences and Informatics, in the University of Edinburgh's Medical School and a Fellow of the Higher Education Academy (HEA). She is the joint theme lead for 'social science and public health' throughout the Edinburgh medical curriculum and is also responsible for the development of, and teaches on the Year 1 module Health, Ethics and Society. Dr Kathleen Kendall is Associate Professor of Sociology as Applied to Medicine in the Faculty of Medicine at Southampton University. She is the subject lead for Sociology within the Faculty and also teaches on the Global Health and Ethics in a Complex World interfaculty modules. While at Southampton she has held various educational leadership roles including developing and implementing a new curriculum. She has received the Vice-Chancellor's Teaching Award three times. Her educational research has included work on diversity teaching and student well-being. Dr Sara MacBride-Stewart is a Lecturer in the School of Social Sciences, teaching in the School of Social Sciences, and in the Cardiff Medical School. She has previously worked as a Research Fellow in CISHE (Cardiff Institute of Society Health and Illness) at Cardiff University School of Social Sciences, and at the University of Canterbury, New Zealand. Her research interests are broad, with current projects on gender and sustainable place-making, representations of dying well, equalities and sexualities, Harden J, Kendall K, MacBride-Stewart S MedEdPublish http://dx.doi.org/10.15694/mep.2016.000166 Take Home Messages