Relevant behavioural and social science for medical undergraduates: a comparison of specialist and...

Relevant behavioural and social science for medicalundergraduates: a comparison of specialist andnon-specialist educatorsSarah Peters

1

& Andrea Livia2

AIM To compare what medical educators who arespecialists in the behavioural and social sciencesand their non-specialist counterparts consider to becore concepts that medical graduates shouldunderstand.

BACKGROUND Previously perceived as �nice toknow� rather than �need to know�, the General Med-ical Council (GMC) now places behavioural and so-cial sciences on the same need-to-know basis asclinical and basic sciences. Attempts have been madeto identify what components of these topics medicalstudents need to know; however, it remains unknownif decisions over programme content differ depend-ing on whether or not educationalists have specialistknowledge of the behavioural and social sciences.

METHODS In a survey of medical educationalistswithin all UK medical schools, respondents wereasked to indicate from a comprehensive list of psy-chological, sociological and anthropological conceptswhat they considered a minimally competent gradu-ate should understand. Comparisons were madebetween the concepts identified by specialist beha-vioural and social science (BSS) educators and thosewithout such training.

RESULTS Despite different disciplinary backgrounds,non-specialist educators largely concurred with BSSspecialist educators in the concepts they consideredtomorrow’s doctors should know about. However,among BSS specialists there remained disagreementon what BSS content was relevant for graduates. Dif-ferences reflect specialist knowledge and recognition

of the role of theoretical underpinning of BSS andreveal gaps in non-specialists knowledge.

CONCLUSIONS Educationalists with formal train-ing in the full range of behavioural and socialsciences should be involved in the development ofBSS curriculum content at both national andschool levels.

KEYWORDS *education, medical, undergraduate;*attitude of health personnel; *teaching; students,medical ⁄ *psychology; social sciences ⁄ *education;behavioural sciences ⁄ *education; curriculum

Medical Education 2006; 40: 1020–1026doi:10.1111/j.1365-2929.2006.02562.x

INTRODUCTION

The term �behavioural and social sciences� (BSS)incorporates the cognate disciplines, including psy-chology, sociology and anthropology. The contri-bution of BSS within undergraduate medicaleducation has increased over the past 50 years. Inhis landmark report, Flexner argued for not onlyan increased scientific basis of medicine, but thatdoctors should have a socially orientated perspec-tive of medical practice.1 Until recently, such topicswere viewed largely as �nice to know� rather than�need to know�, and were introduced most com-monly during the pre-clinical phase of learning.2

Psychologists and sociologists often delivered lec-ture-based teaching on key psychological andsociological theories using a service teachingmodel. Hence the task for psychologists and soci-ologists was largely an unrewarding one of publicrelations (i.e. presenting a case of why BSSwas valuable to medical training); the areas of

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1Division of Psychiatry, University of Liverpool, UK2Division of Primary Care, University of Liverpool, UK

Correspondence: Sarah Peters, Department of Psychiatry, University ofLiverpool, Royal Liverpool Hospital, Liverpool L69 3GA, UK. E-mail:[email protected]

� Blackwell Publishing Ltd 2006. MEDICAL EDUCATION 2006; 40: 1020–10261020

behaviour and social sciences to which medicalstudents were exposed was often dictated by theinterests and efforts of individuals �on loan� fromother departments. Such teaching was often integ-rated poorly with other elements of the course andwith the practicalities of clinical practice (i.e. thework for which medical students are being trained).Hence it is not surprising that students evaluateBSS as lacking relevance.3

In 1993 the General Medical Council (GMC) pro-duced its key recommendations for preparing med-ical practitioners for the new century and stated thatall tomorrow’s doctors should:

know about, understand and be able to apply andintegrate the clinical, basic, behavioural and socialsciences on which medical practice is based (p. 4).4

These recommendations explicitly move behaviouraland social sciences into the �need-to-know� categoryalong with clinical and basic sciences. The interpret-

ation of what areas of the behavioural and socialsciences medical practice is based on is left open forindividual medical schools to decide other than thenon-specific recommendation of �relevant parts� (p.6).4 Several medical programmes describe havingsuccessfully incorporated learning of BSS into indi-vidual medical programmes5 and in the UnitedStates, although not yet in the United Kingdom,content recommendations for a BSS curriculum havebeen published.6

Concerns remain, however, as to the extent to whichindividual schools’ decisions over what is relevant BSScontent are made by medical practitioners, who mayhave no formal training in the behavioural and socialsciences7 and hence limited knowledge of thetheoretical underpinnings and scope of the subjectsand their relevance to medical practice. As medicalschools increasingly map8 their curriculum, itremains unknown if this aspect of curriculum designneeds input from individuals with formal trainingand expertise in BSS. To investigate this, a study ofmedical educationalists was conducted, to comparethe core behavioural and social science concepts thatBSS specialists and non-specialists involved in med-ical education expect tomorrow’s doctors to have atleast a minimal understanding of.

METHOD

A postal survey was sent to 214 participants (seebelow). In this, participants were offered a list ofbehavioural and social science concepts and asked toindicate for each �what level of understanding do youexpect a minimally competent graduate to have?�. Itemswere presented alphabetically. For each item,respondents were asked to indicate if the concept was(a) relevant knowledge for a new graduate and (b)what level of knowledge should be achieved (be ableto describe accurately, be able to describe and applyto other contexts, be able to describe, apply andcritically appraise). An option was also available forrespondents to indicate that they �didn�t know’.Responses were scored 0 (don’t know) ) 4 (applyand critically appraise). A mean score for eachconcept for BSS specialists and non-BSS specialistswas calculated. The concepts were subsequentlyranked in order of importance based on the totalscore given to it by the respondent groups.

Identifying the concepts

Ninety-three concepts were identified from key sou-rces. These included BSS textbooks recommended

Overview

What is already known on this subject

• Behavioural and social sciences (BSS) arecore components of medical educationand practice.

• Design, assessment and delivery of BSSvaries considerably between medicalschools and educationalists trained in BSSare not always involved.

What this study adds

• Educationalists with and without trainingin BSS identify similar concepts that med-ical graduates need to understand

• Additional concepts that were identifiedreflect specialists’ particular area of exper-tise and reveal a lack of the basic theoret-ical underpinnings of BSS by non-specialists.

Suggestions for further research

• Investigation of the barriers that operate toprevent more effective implementation ofBSS in undergraduate and postgraduatetraining and ways of overcoming these.

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for use in undergraduate and postgraduate psychol-ogy and sociology courses; applied BSS textbooksintended for use in medical education; GMC guide-lines for undergraduate education; and, where avail-able, published programme curricula from medicalschools. Concepts were categorised as exclusivelypsychological (n ¼ 35, e.g. attribution theory,coping ⁄ appraisal, memory); exclusively sociological(n ¼ 31, e.g. power and autonomy, social theories ofthe body, illness narratives); or �applied� (e.g. n ¼ 26,e.g. psychological and sociological factors indrug use, behavioural therapy, compliance andadherence).

Identifying the sample

A sample of behavioural, social and medical scientistswith an interest in, or responsibility for, BSS at UKmedical schools was identified. Formal organisations(e.g. Medical Sociology UK, the British PsychologicalSociety, The Higher Education Academy subjectcentre of Medicine, Dentistry and Veterinary Medi-cine, Association of the Study of Medical Education)and informal networks (colleagues, website searches,nominations by heads of medical schools) wereapproached and eligible individuals identified. Fur-ther nominations of colleagues involved in BSS med-ical education were included until no new namesemerged. Thus the BSS community and hence thesurvey sample was collated using a �snowball� approach.This process continued until no new individuals werenominated. A total of 214 individuals were identifiedand sent a postal survey. Individuals not currentlyinvolved in delivering BSS teaching to medical stu-dents or closely involved in delivery ⁄ design of a UKmedical curriculum were excluded.

In order to differentiate individuals who had formaltraining in a behavioural or social science and thosewithout, details of qualifications and professionalbackgrounds were obtained. Respondents were cate-gorised as �specialists� if they had at least an under-graduate degree in a behavioural or social sciencediscipline (e.g. psychology, sociology, anthropology).The remaining group of educationalists were catego-rised as �non-specialists�. Further information of otherwork commitments and location were also gathered.

RESULTS

Of the 214 individuals identified, 140 (65%) respon-ded. Of these, 27 (13%) surveys were returned butwere excluded from the analyses because the parti-cipant was no longer involved in BSS teaching in

relation to medical education. A further 20respondents returned incomplete surveys; 91 com-pleted surveys were returned (43% of full sample,49% valid sample). All UK medical schools wererepresented in the original sample and 29 (of 31)schools were represented in the completed surveys.

Description of sample

Discipline background

Among respondents, 63 (69%) participants wereclassified as �BSS specialists�. The remaining 28participants (31%) were categorised as �non-BSSspecialists�. These primarily had backgrounds inmedicine (general practice, n ¼ 13; psychiatry, 5;public health, 2; obstetrics, 1) or allied professions(nursing, n ¼ 2; pharmacology, 1). The remainingrespondents had backgrounds in education (n ¼ 2),health economics and epidemiology (n ¼ 1 each).Among the BSS specialists were sociologists (n ¼ 31),psychologists (22) and anthropologists (10). Ofthese, 57 (95%) had achieved a higher postgraduatequalification (PhD, MD or DPhil) compared with 4from the non-specialist educationalists (v2 ¼ 50.92,d.f. ¼ 1, P < 0.001).

Other work commitments

While for 79%, undergraduate medicine was themain degree that individuals taught on, only 17%taught exclusively undergraduate medicine. Otherteaching commitments included undergraduate de-grees in non-clinical (psychology, sociology) andclinical subjects (dentistry, nursing, physiotherapy)and a wide range of postgraduate degrees (research,health psychology, clinical psychology, medical soci-ology and public health).

Respondents were employed primarily as academicstaff and as such had remits for progressing aresearch career alongside teaching and administra-tive responsibilities (n ¼ 82). These ranged fromlecturer (n ¼ 32), through senior lecturer (30),reader (1) to professor (19). Seven respondents wereemployed as research staff and 2 were medicalpractitioners without a university appointment. Fromthe responses, it was not possible to ascertainconfidently what proportion of the sample also hadcurrent clinical commitments.

Location

Most staff were located in medical university depart-ments (e.g. psychiatry, primary care; n ¼ 52) or

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departments of medical education (n ¼ 8). Otherswere in BSS university departments (e.g. psychology,sociology; n ¼ 23). The remaining participants were inother university departments (e.g. nursing n ¼ 7) or inthe NHS (n ¼ 1). Specialists were more likely thannon-specialists to be housed in a non-medical univer-sity department (v2 ¼ 15.91, d.f. ¼ 4, P < 0.005).

Relevance of concepts

There was wide variation in how relevant conceptswere considered to be among the respondents. Ofthe 93 concepts, only 1 (evolutionary psychology) wasdeemed unanimously to be irrelevant. No conceptwas thought unanimously to be relevant. Meanrelevance ratings did not differ significantly betweenconcepts that were categorised as psychological,sociological and applied.

Agreement of concepts between specialists and non-specialists

There was a striking level of agreement between thespecialists and non-specialists over which conceptswere considered most relevant. First, scores of howrelevant the concepts were considered did not differbetween the specialists and non-specialists for eithersociological (U ¼ 249.5, d.f. ¼ 65, P > 0.01), psy-chological (P ¼ 174, d.f. ¼ 64, P > 0.01) or applied(U ¼ 222, d.f. ¼ 72, P > 0.01) concepts. Further-more, for each of the 93 concepts there was nodifference between specialists and non-specialists asto whether it was rated as relevant or not (for eachcalculation, P > 0.01). Finally, of the top 30 con-cepts identified by each group, 27 were in common(Table 1). Of these, 17 were agreed by non-special-

ists and both social scientists and behavioural scien-tists.

In contrast, a difference in the relevance rating wasfound between the discipline specialties of socialscientists (sociologists and anthropologists, n ¼ 41);behavioural scientists (psychologists, n ¼ 22) andnon-BSS specialists (n ¼ 28; F ¼ 5.579, d.f. ¼ 2,P < 0.01). While all three groups agreed on therelevance of sociological concepts (F ¼ 1.006,d.f. ¼ 2, P ¼ 0.371), behavioural scientists rated boththe psychological and applied concepts as morerelevant than did the social scientists (F ¼ 11.67,d.f. ¼ 2, P < 0.001 and F ¼ 8.38, d.f. ¼ 2, P < 0.001,respectively). A number of concepts were rankedhighly (within top 30) but were unique to one of thespecialties. These reveal areas of particular interest tospecialists (see Table 2). Only one concept (medicaland alternative models of healing) was identified byboth groups of BSS-specialists, but not the non-BSSspecialists.

DISCUSSION

It was possible to identify consensus about the keybehavioural and social science concepts with whicheducationalists consider new graduates should befamiliar. These are similar to those identified by USeducationalists, which fall into themes of mind–bodyinteractions in health and illness, patient behaviour,physician role and behaviour, physician–patientinteractions, social and cultural issues in health careand health policy and economics.6 This is the firsttime a similar exercise has been systematicallyundertaken in the United Kingdom and among

Table 1 Concepts identified by non-BSS and BSS educationalists (n ¼ 91); concepts are presented in order of ranking by non-BSS educationalists

Key concepts as agreed by non-BSS and BSS educationalists

1. Disability and handicap 15. Health care seeking behaviour2. Experience of acute ⁄ chronic illness 16. Health care priority setting and rationing (SS)3. Experience of hospitals and health care systems 17. Psychological and sociological perspectives of death, dying and bereavement4. Culture 18. Social aspects of disease5. Illness behaviour 19. Models of care, e.g. patient-centered care6. Health beliefs and illness cognitions 20. Psychological and sociological perspectives of mental illness7. Models of doctor–patient communication 21. Social Class and socio-economic status (SS)8. Compliance and adherence 22. Psychological and sociological perspectives of eating and weight control (BS)9. Discrimination 23. Quality of life (BS)

10. Gender (SS)* 24. Life cycle (SS)11. Pain management (BS) 25. Psychological and sociological theories of pain (BS)12. Health education and promotion 26. Stress, challenges and the stress response (BS)13. Lay perceptions of health and illness (SS) 27. Psychological and sociological perspectives of smoking14. Ethnicity

*Where agreement was not unanimous (non-specialists, social scientists and behavioural scientists), specialist category in agreement (social scientist,SS; behavioural scientist, BS) is given in parentheses.

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respondents there was general agreement betweeneducationalists with and those without formal BSStraining as to which concepts these were.

However, despite the high level of agreementbetween the specialists and non-specialists, therewere some disagreements, in particular among thespecialists from social science and behaviouralscience backgrounds. These differences largelyreflected their area of expertise and disciplineperspective and, to some extent, reflect specialists’recognition of the core value of theory. Theoriesoften form the basis for the more �applied� conceptsand as such can be considered foundation know-ledge, in the same way that knowledge of the keyprinciples of chemistry can understood as a prere-quisite (and therefore integral) to learning phar-macology. For example, while non-specialistsidentified �behaviour therapy� as a key concept fornew doctors, specialists with a background in beha-vioural sciences identified instead �conditioning andlearning theories� as a core concept. Social learningtheory is the foundation model upon which beha-viour therapy is based and it is not possible tocomprehend this therapy without an understandingof this theoretical principle. Similarly, for sociolo-gists, understanding theories of the social structureof society is central to understanding the import-ance and significance of the sick role. Hence,although differences in choices between the spe-cialists and non-specialists were few they areimportant, because first, they reveal a lack ofknowledge on the part of the non-specialists of thetheoretical basis of BSS and secondly, highlight theneed for BSS content to have an explicit practicalapplication in order for non-specialist educational-ists to recognise its relevance to medical training.9

Together these findings suggest that while medicalnon-specialists largely agree with BSS specialists, thelatter group is heterogeneous and should not beconsidered as a single body of knowledge. Only 17 ofthe 30 concepts identified by the non-specialists wereidentified by both social and behavioural scientists.Hence, in order to identify meaningful BSS curriculathat reflect relevant BSS, development must be incollaboration with the full range of BSS experts,clinicians and professional bodies.

There are a number of weaknesses of this exploratorystudy that should be acknowledged. First, the samplewas identified using a combination of contactingmembers of relevant networks of educators andbehavioural and social scientists and by �snowballing�contacts. This was the first attempt to identify thisgroup of educators and, although every attempt wasmade to ensure that the sample was as comprehensiveas possible, it remains unknown how representative it isof those involved in delivering medical education. Asall medical schools were included in the sample andthe process of identifying individuals continued untilno new names emerged, we are reasonably confidentthat all key BSS medical educators were approachedand had an opportunity to respond.

A major weakness of the study is that the responserate, although respectable for a �cold call� postalsurvey, was rather low. A number of surveys werereturned with notes to say the individual was nolonger involved in medical education. It is likely thata proportion of the unreturned surveys were alsofrom individuals who had left medical education andhence would not be eligible in the study ) hence thepoor response rate from eligible participants may besomewhat higher than that documented.

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Table 2 Constructs unique to specialities (position ranked within top 30)

Non-BSS specialists

n ¼ 28

Behavioural scientists

n ¼ 22

Social scientists

n ¼ 41

Sick role (18) Measurement of subjective symptoms(e.g. pain ⁄ fatigue) (4)

Social structures within the family, workplace andsociety (17)

Behavioural therapy (28) Medical and alternativemodels of healing (6)

Medical and alternative models of healing (26)

Psychological and sociological perspectivesof alcohol consumption (29)

Psychological processes of postoperativerecovery (14)

Social perspectives of health care (20)

Conditioning and learning theories (15) Medicalisation theory (22)Coping and appraisal (20) Social structures within the medical profession (23)Psychological and sociological perspectivesof drug use (23)

Poverty (24)

Cognitive-behavioural therapy (24) Stigma (25)Psychological and sociological perspectivesof sexuality and sexual behaviour (30)

Life events (29)

Social support (30)

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Nevertheless, a potential source of bias in the sampleis that among the eligible questionnaires returned,there was greater representation of BSS specialistscompared with non-specialists, i.e. the sample wasbiased towards medical educationalists who were BSSspecialists. This is perhaps unsurprising, as this is thegroup which has the greatest interest in (and most tobenefit from) developments in this field. Similarly, itis also likely that the non-specialist respondents arealso those with greater interests in this topic and,although lacking formal training and qualification inthese fields, may be individuals with greater know-ledge of BSS gained via informal self-directed learn-ing compared with their non-responding medicaleducational counterparts. Hence the sample is likelyto be biased towards educationalists (both specialistsand non-specialists) who are particularly interested inand knowledgeable about BSS learning within med-ical education. This may explain partly the high levelof agreement between the specialists and non-spe-cialists in this study, and greater levels of disagree-ment may be exposed in future work comparing viewsof BSS specialists with those of a less interested andmotivated (but possibly a more representative) groupof non-specialists. Indeed, these differences may bemore marked than the differences found in thecurrent study between the behavioural and socialscientists ) further supporting the argument forincluding BSS specialists within medical educationcurriculum development.

The finding that many of the identified BSS specialistsin the sample had left medical education highlights adifficulty for BSS educators working within this field.The application of BSS to medical education is still arelatively young discipline, and as such suffers from apaucity of formal networks and available disciplinementors and an ill-defined career structure.7 In addi-tion, numerous barriers to its implementation con-tribute to negative experiences of working withinmedical education.10 Such staff are often located (andreport feeling marginalised) within medical depart-ments and hence are isolated from their academicpeers, while expected to progress a research career intheir discipline field. In this study’s sample only aminority of respondents’ teaching commitments wereexclusive to training medical undergraduates whichsuggests further, potentially conflicting, demands.Consequently, it is unsurprising that most BSS medicaleducators eventually leave medical education, citingthe primary reason as �to seek a stronger identity with abasic discipline� (p. 934).11 This represents a signifi-cant loss to medical education of individuals who havedeveloped a unique blend of skills and knowledge:specialist knowledge of BSS (this study found very high

levels of academic attainment in their discipline);knowledge of content and educational methods ofmedical training; knowledge of the complex demandsof clinical practice; and ability to communicate therelevance of BSS to students and programme directors.Medical schools need to recognise that design, assess-ment and delivery of BSS in medical educationrequires input from individuals with specialist exper-tise and to consider the support structures available tothese academics.

A further limitation of the study is that it is not knownhow respondents interpreted the core concepts. Forexample, the term �sick role� has particular meaningto sociologists who will be conversant with the theoryunderlying this. However, the term also has under-standing within lay groups. How aware the non-specialists were of the particular sociological meaningor more lay meaning remains unknown. A surveymethodology does not offer the scope to ascertain anindividuals understanding of the concepts or toprovide contextual information to help respondents.Further qualitative research would help clarify thisissue.

Unlike their US and Canadian counterparts, UKmedical students do not sit national licensing exam-inations but are assessed by their medical school who,as a consequence, maintain a high degree of indi-vidual autonomy over the curriculum content andmethods of delivery. This enables schools to developand experiment with new ideas and maintain aschool philosophy and therefore provides studentswith choice over their educational experience. Theintended outcome ) a good medical practi-tioner ) is common to all schools. It has beensuggested that avoiding developing a common corecurriculum results in a lack of equivalence in com-petency across different schools. The principle argu-ment for the development at national level of acommon curriculum is that it standardises contentand quality across schools. This debate has runinconclusively for many years12 and most recently hasfocused on the area of fitness for practice.13

The establishment of guidelines for a commoncurriculum or set of core competencies in BSS couldhelp, rather than restrict, medical educators who, asindividuals, do not have the knowledge base of thefull range of behavioural and social sciences. It wouldalso assist professional bodies in ensuring quality ofbasic medical education is maintained across schools.

A barrier to developing such guidelines has been thelack of organised communication between such indi-

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viduals: no network exists to take on the task ofidentifying and agreeing a core curriculum. A recentdevelopment brought together a group of medicaleducationalists with behavioural and social scienceexpertise7 and led subsequently to the formation of thenetwork of behavioural and social science teachers(BeSST) in medical education, which provides a forumfor debate and dissemination of good practice andresearch into core content14 and methods for integ-rating BSS in medical education and improvingcommunication with other medical practitioners andeducators. This study is presented as a piece of thesediscussions.

The debate over to what extent the behavioural andsocial sciences have a role in training effectivemedical practitioners has moved forward. Furtherwork is now needed to not only establish what leveland breadth of understanding students need to have,but also research is needed to understand more fullythe processes operating to prevent more successfulintegration of this relevant knowledge base intomedical training.10 It is likely an appropriate place tobegin is in improving communication among BSSspecialists involved in medical training as well asbetween medical and BSS educationalists.

CONCLUSION

Specialists and non-specialists agree on what BSScontent is core for new medical graduates. Differ-ences may reflect lack of knowledge of the topic areaamong non-specialists. There is a need to include andsupport educationalists with expertise in the beha-vioural and social sciences in curriculum design atnational and institutional levels. A role for greatercommunication exists among BSS specialists andnon-specialists within medical education.

Contributors: both authors contributed to the studyconception, design, data collection and analysis, and todrafting and revising the paper.Acknowledgements: thanks to Judy Rock, Chris Bundy andLis Cordingley for thoughtful comments on an earlier draftof the paper.Funding: none.

Conflicts of interest: none.

Ethical approval: the authors state that ethical approvalwas not required.

REFERENCES

1 Flexner A. Medical Education in the United States andCanada. Report to the Carnegie Foundation for theAdvancement of Teaching. Boston: Updyke 1910.

2 Bundy C, Cordingley L. Moving on to the core curri-culum. Psychologist 2003;16:121.

3 Sheldrake P. Behavioural science in the medical cur-riculum. Soc Sci Med 1973;7:967–73.

4 General Medical Council. Tomorrow’s Doctors. Recom-mendations on Undergraduate Medical Education. London:General Medical Council 2003.

5 Satterfield JM, Mitteness LS, Tervalon M, Adler N.Integrating the social and behavioral sciences in anundergraduate medical curriculum: the UCSF essentialcore. Acad Med 2004;79:6–15.

6 Cuff PA, Vanselow NA, eds. Improving Medical Educa-tion. Enhancing the Behavioral and Social Science Content ofMedical School Curricula. Washington: Institute ofMedicine, National Academies Press 2004.

7 Russell A, van Teiljlingen E, Lambert H, Stacy R. Socialand behavioural science education in UK medicalschools: current practice and future directions. MedEduc 2004;38:409–17.

8 Harden RM. AMEE guide, 21: curriculum mapping: atool for transparent and authentic teaching andlearning. Med Teach 2001;23:123–37.

9 Volpe R. Behavioral science theory in medical educa-tion. Soc Sci Med 1975;9:493–9.

10 Benbassat J, Baumal R, Borkan JM, Ber R. Overcomingbarriers to teaching the behavioral and social sciencesto medial students. Acad Med 2003;78:372–80.

11 Badgley RF, Bloom SW. Behavioral sciences and med-ical education: the case of sociology. Soc Sci Med1973;7:927–41.

12 MacLeod SM, McCullough HN. Social science educa-tion as a component of medical training. Soc Sci Med1994;39:1367–73.

13 Wass V. Ensuring medical students are �fit for purpose�.BMJ 2005;331:791–2.

14 Bundy C, Cordingley L, Peters S, Rock J. Towards acore curriculum for psychology in undergraduatemedicine. Conference Workshop, Association for MedicalEducation in Europe, Amsterdam, NL, August 2005.

Received 5 December 2005; editorial comments to authors 20December 2005; accepted for publication 23 March 2006

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