42: Teaching Behavioral Medicine: Theory and Practice

Today it is widely recognized that high-quality patient care is built on a foundation of knowledge and abilities in the basic, clinical, and behavioral and social sciences. Social and behavioral factors are estimated to contribute to more than half of all causes of disease and death in the United States, including cancer, heart disease, chronic obstructive pulmonary disease, and type II diabetes. Growing knowledge of the complex behavioral, social, and psychological contributors to disease has important implications for clinical practice and physician education, both formal and informal. Physicians must understand these factors and their interrelationships, and be able to apply this knowledge in the care of patients to optimize health outcomes as well as to equip them with the skills that promote their own sense of well-being, foster lifelong personal and professional growth, and decrease feelings of cynicism and burnout.

Whereas many health training programs have incorporated behavioral and social science content into their formal education, many curricula remain fragmented, incomplete, and marginalized. Emphasis on formal curricular development may also overlook the importance of the informal curriculum (or learning environment)—the physician and resident modeling of behaviors and attitudes that medical students experience every day. Therefore, educators must be attentive to both influences on student education. Using current theories of learning, this chapter illustrates innovative educational methods that integrate the formal and informal curricula to effectively teach social and behavioral science (SBS).

The IOM report, Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula, identifies 26 topics in six SBS domains that are important to the education of future physicians (see Table 42-1). The demographic and social contexts contributing to the need for such training in the behavioral and social sciences have been well documented. Nevertheless, several decades of efforts to teach this content have resulted in mixed success. Medical education literature clearly identifies several types of difficulties specific to the teaching of SBS in the formal curriculum, including the marginalization of SBS content, lack of appropriately trained faculty, timing of teaching the SBS content, mismatch between teaching methods and context of use, and failure of social scientists and clinicians to work together to create effective learning experiences. It is not difficult to find examples. SBS content may be treated as an “add on” to the traditional basic science and clinical curricula. Medical training programs may lack support and incentives for faculty to include SBS content, and for career development programs in SBS. SBS topics may fit into available time slots rather than taught at the appropriate times in the trainees’ development and in the appropriate depth. For example, topics such as death and dying are often covered in small-group discussions in the first or second year and not revisited in any formal way in the clerkship years, yet research on knowledge use and acquisition concludes that there is little immediate transfer of learning from one context of use to another. Thus, students who discuss death and dying only in the early year or two of training (academic context) will be challenged to exhibit professional and humanistic behavior in the presence of real patients (practice context) without further formal training in the clinical context.

There are also additional, well-documented structural impediments from a systems perspective to fully realizing the successful integration of SBS into the larger medical education curriculum. Medical education is by and large examination driven, quantitative in nature, and competition among and between students is based on these numerical rankings. This system continues to perpetuate the marginalization of SBS to a supporting or secondary role in the minds of faculty and students in favor of more influential “objective” measures. For example, on the national level, the Association of American Medical Colleges’ Medical College Admission Test (MCAT) as well as other high-stakes examinations (e.g., USMLE Step 1) are not Pass/Fail despite sufficient evidence that once a learner achieves a particular threshold of success on the examination there is no difference in clinical performance based on achieving a greater numerical score. Yet, despite this evidence, many institutions continue to use the specific scores to screen applicants for entrance to US medical schools and residencies, and school administrators are under pressure, and in some cases even rewarded, for only recruiting and admitting those with the highest test scores instead of developing criteria that would focus on such areas as the 26 topics in the six SBS domains as the discriminating factors.

In response to similar concerns, Canada’s McMaster University developed the Multiple Mini-Interview (MMI) for use in the admissions process. Resembling an objective structured clinical examination (OSCE) the MMI consists of short-interview stations that focus exclusively on noncognitive domains. The open-ended interviewer–applicant interactions instead revolve around areas such as the ability to collaborate, communication skills, and moral reasoning. By focusing on these noncognitive professional abilities the MMI has consistently demonstrated greater reliability (i.e., around 0.75) than standard interview methods to accurately assess for these qualities, which are grounded in SBS and valued in clinical practice. It has also been established that the MMI has a significant and moderately large positive correlation in predicting clinical clerkship performance as well as a statistically significant positive correlation for those subsections of national licensing examinations assessing professional quality domains.

On the local level, many courses in the basic sciences lend themselves to “multiple choice” measures making the evaluation of SBS content difficult to objectively evaluate given the time and resources SBS curriculum often requires in both teaching and evaluating. Therefore, even if SBS content is woven into the curriculum, it is often not as heavily weighted or given equal focus in course examinations. This not only perpetuates the idea that SBS content is not as important, but for the learner whose measure of success rests on quantitative success (i.e., to get into medical school, a residency, or pass an examination), it creates a systems-induced survival strategy of “if it’s not going to help me on the test then it’s not important.” This mentality or two-tiered system of valuing the objectively quantifiable over the more often subjectively qualitative SBS is as much a systems issue as it is those difficulties specific to the teaching of SBS in the curriculum noted above.

Finally, emphasis on discipline-based knowledge creates another barrier to integration of SBS content. True integration of SBS content requires disciplinary communities to work closely together to establish joint responsibility for knowledge creation, development and dissemination. With the exception of family medicine residency training programs, which have emphasized training in SBS, the same limitations and critiques directed toward undergraduate medical education hold true for graduate medical education as well.

Informal education in the SBS also has presented a challenge. Research indicates that it is the social environment of the medical school, the so-called “informal curriculum,” that guides most aspects of a future physician’s behavior. The role modeling that physicians and residents actually do, much more than what they say, powerfully influences the beliefs, values, and role expectations of physicians-in-training. Patient care and clerkship experiences—where physical, emotional, behavioral, social, and cultural issues become embodied for learners in their patients—have the potential to be particularly important behavioral and social science learning opportunities. Here attending and resident teaching could seamlessly integrate SBS education into daily clinical activities. Unfortunately, studies show that attributes such as social-mindedness and interest in the psychosocial issues embedded in all illness decline rather than improve during this time, and many students experience a diminishment, not enhancement, of their moral values base.

Work must be done to raise faculty and resident consciousness of the power that their words and actions have in shaping students’ perceptions of patients, their specialty and medicine in general. Students and faculty benefit alike from the opportunity to process and learn from their own experiences, making each more conscious of the relationship between their values, actions, and behavior, and better prepared to model and teach the SBS aspects of patient care and the practice of medicine.

Educational Learning Theories Foundational to Creating Social and Behavioral Science Curriculum

As medical training programs seek to integrate their formal and informal curricula to improve SBS education, current learning theories provide a useful underlying framework. Understanding the various theoretical orientations will allow educators to address concerns raised in the IOM report about incorporating the most appropriate teaching methodologies when teaching SBS. The five learning theories described in the adult learning literature include behaviorist, humanist, social learning, cognitivist, and constructivist orientations. An overview of these orientations, associated educational methods, and theoretical principles are briefly summarized in Table 42-2.

Teaching Methods Foundational to Learning Social and Behavioral Sciences

The five Theoretical Orientations are presented as a frame for teaching SBS. A brief description of each of the suggested methods under each orientation is provided. Specific case illustrations applying the suggested methods in teaching and SBS are also included. In some cases, the examples provided by the authors could be categorized under more than one orientation. However, the main purpose of the illustrations is to provide a wide sampling of educational vignettes that integrate the formal and informal curricula as a foundation upon which to build an SBS curriculum for varying levels of medical trainees.

The behavioral orientation is very useful for teaching technical, clinical, and psychomotor skills as well as other observable behaviors. Direct observation of trainees with real or standardized patients (SPs), particularly when trained observers utilize well-designed checklists and/or rating forms, provides valuable formative and summative assessment about trainees’ social and behavior science competence.

Direct observation: Direct observation of trainees is an important way to foster medical trainees’ basic clinical and communication skills as well as interpersonal and professional behavior; yet it is infrequently done. Here resident or student patient care competency, contextualized in the everyday interactions of the informal curriculum, or institutional culture, is brought into the formal curriculum for purposes of formative feedback.

Direct observation is itself a skill that requires faculty training and practice. Faculty training should focus on standardizing, to the extent possible, the behaviors of interest and how to accurately identify such behaviors in the trainees. This is especially important for high-inference behaviors, such as those provided below (see case illustration 1). For example, in the behaviorist approach, what does nonjudgmental communication about a sexually transmitted disease actually look like? Faculty should spend some time discussing these issues as part of the standardization and calibration process.

Standardized patients: In an effort to standardize training of doctor–patient communication, physical examination skills, and other areas, medical schools, residency training programs, and the National Board of Medical Examiners (NBME) have progressively moved toward using SPs. Simulations can be videotaped and used for self or group reflection. Paradigmatic examples could also be used for faculty development in recognizing and developing intercoder reliability on behavioral evaluations. From these examples, skills in providing feedback and creating learning opportunities could be developed.

The humanistic orientation promotes learning activities that are autonomous and self-directed for learners to develop a deeper understanding of the path needed to reach their full potential and, in return, recognize the humanness in themselves as well as their patients. Problem-based learning (PBL) and exercises that promote self-assessment are educational tools for fostering humanistic-style learning.

Problem-based learning: Problem-Based Learning is a learner-centered method of small group learning usually built upon paper cases developed from real patient care vignettes. The case discussions generally evolve over several days or weeks with progressive disclosure of information to the students upon request or at critical times. Students identify their own learning issues and resources for finding solutions to their learning needs. A facilitator guides the process of the small group sessions but does not serve as a content expert for the learners. This process promotes autonomous, self-directed, lifelong learning skills and prompts learners to reflect on the cultural assumptions or observations that shape their list of learning issues and resources, providing an opportunity for integration of the informal curriculum.

Guided self-assessment: Self-assessment exercises can be built into a variety of educational activities stimulated by prompting questions posed by medical educators. Creating a forum for students to safely discuss their personal reflections on journal entries or information collected as part of self- and peer-assessment programs can promote self awareness, personal growth, and professional development in one-on-one and group settings and is another example of formal/informal curricular integration. Students are asked in the formal curriculum to reflect upon and assess their abilities and performance in both the formal and informal curricula.

To be effective, self-assessment is not performed by the student in isolation. The impact of self-assessment is most valuable when performed with guidance, which we define as either externally provided data (e.g., peer assessment, etc.) or in conjunction with an advisor or mentor.

According to the social learning orientation, learners assimilate new information and assume new roles through role modeling, behavioral rehearsal, and attending to observed behaviors. This orientation is central to the importance of the informal curriculum on shaping the professional development of trainees. Identifying ways to make stories about role models within an academic community more tangible and visible will inevitably lead to a heightened awareness about the importance of role modeling. Educational methods that promote collaborative, cooperative learning such as team-based learning (TBL) also highlight the complexities and value of collective problem solving and resourcefulness.

Role modeling: Role modeling shapes the professional culture or informal curriculum of an organization and substantially impacts the professional identity of trainees. The window into the impact of medical educators’ role modeling can be seen in the trainees’ stories about their learning environment. How the faculty conduct themselves and live their values through their actions can be influenced by integrating trainees’ stories into the “formal” content of faculty development programs.

Team-based learning: Team-based learning has potential to be a major vehicle or education methodology for SBS. This methodology promotes active learning and effective team skills without requiring intensive faculty resources for tutoring sessions. TBL uses principles to develop small groups of students into effective learning teams who not only learn course content but also high-level content application, problem solving, and effective team interaction.

The three-part team learning instructional strategy puts these principles into action. Part I is the initial exposure to the concepts of an instructional unit through a Readiness Assurance Process. The Readiness Assurance Process begins with individual preclass work (through assigned readings, work on computer modules, and other modalities). It includes students completing an Individual Readiness Assurance Test (IRAT) during the first few minutes of class that covers the preassigned material. Immediately following the IRAT, the teams take the same test (a Group Readiness Assurance Test, or GRAT), which allows for peer discussion of important course content. The IRAT/GRAT tests are reviewed in class to ensure all students have thorough knowledge of foundational content. The instructor provides focused feedback and instruction on areas demonstrated to need additional clarification. Teams have the opportunity to appeal and defend any answers marked incorrect. This allows teams an opportunity to further review and discuss difficult concepts.

Upon completion of the Readiness Assurance Process, teams are ready to begin work on team application assignments (Part II). Team assignments allow students to increase their understanding of the main unit concepts by using them to solve a problem. Assignments generally ask team members to reach a decision (rather than write a report) and thus stimulate a high level of team interaction. At a given point, all teams simultaneously reveal their decisions and begin cross-team feedback and discussion. Team assignments for a given instructional unit usually progress from the simple to the more complex. Individual team members prepare for team assignments outside of class and then work together with their team members in class to reach a consensus conclusion. After sufficient team application practice, the instructor reviews the major course content and application learning points and students are formally assessed on an individual basis on their ability to solve a final application problem (Part III).

These team-learning experiences provide a perfect opportunity for learners to move from “stage-to-stage” as part of the process of professional development and role recognition. The experience of being a member of a TBL group also directly addresses key SBS learning objectives, including “identify ways to work effectively as a part of a team” and “engage in activities that foster the development of socially responsible leadership skills” (refer to Table 42-1 under the Physician Role and Behavior Domain). TBL also formally includes Peer Assessment in the sessions and can incorporate Self-Assessment as well.

Student narratives describing their experiences in the informal curriculum can provide opportunities for TBL groups to integrate multiple SBS competencies/domains into a discussion that addresses key learning objectives and exploration of the science supporting these objectives. Used in this way, narrative has the potential to utilize personal experiences of the informal curriculum to enhance the relevance and enrich the content related to formal curricular objectives.

The cognitivist orientation suggests that learners use cognitive tools such as insight, information processing, perceptions, and memory to facilitate learning by assigning meaning to events. Use of cognitive maps and reflection exercises are educational methods for promoting the cognitivist orientation.

Concept mapping: Concept mapping exercises provide trainees with a tool to graphically depict their understanding of complex problems or systems. Concept mapping offers a way for learners to incorporate new information into existing knowledge frameworks by associating relationships. Concept mapping can be used longitudinally to visually represent the progressively more complex neural connections in the developing mind. One can readily see the increasing complexity, hierarchical layers, and growing complexity of cross-linking between the pre- and postfigures (Figures 42-1 and 42-2) and when learners’ cognitive development is tracked across time.

Analysis and reporting of developmental changes in concept mapping within individuals across time and between groups can be performed. Qualitative analysis of phrases and terms entered onto maps can be performed using software packages along with some quantitative or semiquantitative measures based on scoring schemes reported elsewhere.

Reflective exercise: Medical training programs are increasingly incorporating 360-degree (multisource) evaluations for trainees. When accompanied by facilitated one-on-one reviews with mentors and advisors, these sessions offer the opportunity for learners to use a breadth of cognitive tools in an effort to assign meaning to these highly complex and personal data.

The constructivist orientation supports the theory that knowledge is formed within the learner by integrating learning activities and experiences into knowledge and beliefs. The creation of meaning from these experiences emerges through critical reflection on existing beliefs and assumptions. Reflective journaling and active creation of learning or competency portfolios are examples of education methods used by educators to tap into constructivist learning styles.

Reflective journaling: Medical training institutions are including reflective journaling in their curricula. SBS constructs, such as identity, bias, privilege, social connections, and emotional management can be potent personal triggers requiring supported opportunities for reflection and growth. Reflection and reflective practice are essential habits of a good physician. (Although reflection is seen as a teachable skill with lifelong utility, it is especially important in the context of an intensive and challenging training environment.) Journaling exercises can range from brief informal invitations to write one’s thoughts about a personal experience from the informal curriculum, to writing annual letters to one’s self that are personally reviewed, to more extensive narrative writing exercises that are formally analyzed by faculty with expertise in “Narrative Medicine” (see Chapter 45). Reflective journaling can be solely for personal use and review, for one-on-one review with learner-selected and trusted mentors, for de-identified uses within small group seminars, or for required carefully evaluated narrative writing courses. Many guidelines for critical reflection exist. One example is the “LEAP” guidelines (LEAP = “Learning from your Experiences as A Professional”) that teach learners to write reflections similar to medical “SOAP” notes (i.e., the subjective experience, the objective data about the event, the learner’s assessment of causes and possible learning points, and the learner’s plan of what she/he will do next).

Reflective journaling serves to make more seamless the experience of the medical trainees regarding biomedical principles and social/behavioral principles in the context of patient care. Trainees’ narratives can provide clear evidence of their ability to integrate these different dimensions of health and disease, in a more holistic manner than the knowledge measures or other quantitative measures of student performance. With permission, trainee’s personal reflections (stories) can be used to generate new curricular materials linking informal and formal aspects of their training.

Commitment to change statements: Another approach to help learners integrate knowledge and experience is commitment to change (CtC) statements (see student journaling exercise on lifestyle change commitments above under case illustration 1). Research has shown the CtC method does enhance the probability of an individual making a change. At the end of an educational experience, the student is simply asked to write down a limited number of things they wish to change or accomplish as a result of the educational experience. In addition to writing what they would like to do differently, they can provide a rating on how motivated they are to make the change and how difficult they believe it will be to make the change. At a predetermined follow-up time, the student’s CtC statements can be returned to them to reflect on whether they were successful in making the change and why. If they were not successful, they can also reflect on what the barriers were to making the change and lessons learned from the experience.

Portfolios: Learning portfolios aggregate learning products review and analysis by trainees and/or course and residency program directors. Portfolios have been found to be of high utility in documenting evidence of performance in SBS areas, such as self-awareness, professionalism, ethical judgment, and moral reasoning. Trainees can populate portfolios with documented experiences or activities from the formal or informal curricula. Given the sensitive nature of some materials entered into trainees’ portfolios, several institutions have created ways to allow learners to self-populate both “personal” and “academic” versions of their portfolios. For ease of handling data, electronic portfolio tracking systems are increasingly available.

Medical Education Methods Effective for Teaching Behavioral and Social Science

Educational methods found to improve student learning of traditional basic science or clinical content apply equally well to education in the SBS. Below are four examples.

Adult Learning Methods

The central tenet of teaching adult learners is recognizing and engaging their wealth of experience as an educational resource and creating “active” versus “passive” (e.g., lecture) learning activities. SBS lends itself to this approach because learners can often access the content through reflection on their own experience (e.g., racism, homophobia, caring for the elderly), in small group discussions or working together with peers on TBL cases. Students who participate in the learner- centered approach are more likely to go beyond passively absorbing the curriculum; they develop habits of inquiry, reflection, and teamwork as they move forward in the progressive development of a socially enlightened physician identity. In addition, activated learners participate in shaping the curriculum or delivering it to themselves and their peers. Further curricular enhancement can derive from interprofessional TBL experiences, as other disciplines such as nursing and social work have a long history of SBS-focused patient care and curriculum, which can increase its salience and influence on physician problem solving and worldview. These students may be especially motivated to develop and support SBS teaching not only in their practice but as models for future generations of physicians.

Highlight Clinical Relevance

An important mission of all medical schools is to graduate learners who are prepared for medical practice, and SBS curricula are central to this mission. Emphasizing clinical relevance for preclinical and clinical students can counter the perception that SBS lacks practical utility in patient care. Although there is no national consensus framework for presenting SBS material, existing guidelines may prove useful in determining how SBS content can best be implemented into clinical care. Early exposure to longitudinal patient care can provide students with a “lived” experience from the patient’s perspective of interacting with a health care system that the students will soon be in a position to impact clinically, economically, and perhaps in policy. Although less factually based, a salient patient interview may prove far more memorable in illustrating the effects of poverty on health than a required journal article. Similarly, a well-crafted longitudinal patient care experience or PBL case that highlights issues such as substance abuse, social supports, and the value of the therapeutic relationships—while also integrating them with clinical and basic sciences—might more effectively convey those constructs compared to a didactic lecture.

Include A Focus on Quality of Care

An emphasis on quality of care further maximizes clinical relevance for students. Teaching students about the social and behavioral determinants of health, the major impact that SBS problems have on mortality, and methods of addressing these health risks moves the issue beyond a matter of political correctness or social trends. Teaching students how to ask about health-related behaviors and how to facilitate behavior change has direct benefits for quality of care. Teaching about health systems, health care teams, and ways to avoid medical errors clearly relates to quality improvement (QI). If SBS concepts are framed as practical tools to help students become better doctors, the perceived value increases. Furthermore, creating opportunities for students to be involved in actual, small-scale QI projects takes the process from passive knowledge attainment to actively acquiring the skills and efficacy to facilitate a measureable impact on both patients’ and doctors’ lives as well as the health care system as a whole.

Create A Spiral Curriculum

Given the vast amount of information to teach, many educators make the mistake of trying to teach too much at one time. Stand-alone behavioral science courses are so overfull that little time is left to promote clinical application and improve trainee retention. A developmentally appropriate “repetition and elaboration” approach should be created that first introduces the materials on a beginner’s level, and then revisits those same constructs later with greater complexity and learner demand. However, in some instances these SBS linkages may already exist in the formal and informal curriculum, but they are poorly mapped and rarely if ever explicitly identified to the student in a purposeful way. This lack of purposefulness further perpetuates the belief that SBS concepts and curriculum are “just common sense” and do not require the same focus or prioritization as the biomedical sciences. Mapping would help identify areas where SBS concepts occur naturally in the curriculum, which in turn helps educators better identify and elaborate on them in a meaningful way. Mapping would also help curriculum designers identify specific lacunae where SBS needs to be addressed.

The educational methods described above will be minimally effective unless grounded within a community that models and teaches these values, knowledge, and abilities. Serious attention to education in the behavioral and social sciences must, therefore, include attention to the informal curriculum of the institution that so strongly influences the developing professional identity and practice patterns of trainees. The educational methods described below are designed to foster the development of the medical training institution itself.

Promote Relational Practices across the Organization

Teaching behavioral and social sciences in the informal curriculum requires institutional and faculty/staff development that promotes key behavioral and social science-informed (relational) behaviors in the everyday environment. Practices that build relationships include faculty development that enhances both individual and group communication skills. New practices in meetings can enable participants to get to know the person, not just the position, sitting next to them. These include an invitation for participants to “check in” at the start of a meeting and share some small piece of personal or professional information (“My son won his bike race yesterday!” or “My clinical research project was funded!”) that enables a deeper level of interaction. Collaboratively and transparently establishing the meeting agenda at the start of a meeting, ensuring that everyone has the opportunity to speak, and actively seeing and valuing a wide range of perspectives on any particular topic help to create an organizational culture that models the values and behaviors students are taught in their formal education.

Take Time to Examine and Publicize What Is Working Well

Traditional organizational development strategies often begin by identifying what is not working in the institution, the “problem,” and focus on finding ways to avoid, decrease, or solve that problem. This deficit approach to change asks participants to address and study the question “what are we lacking?” In contrast, the organizational development method of Appreciate Inquiry (AI), grounded in positive psychology, challenges conventional approaches with the premise that people are more motivated to engage in change by finding what’s working well and doing more of it. Described by its founder, David Cooperrider:

AI seeks to discover what members of a community are already doing well, and to hold those achievements up as an attainable standard of success. It can be used by medical training institutions to identity existing strengths in key behavioral and social science domains, such as the ability to effectively address mind–body interactions in health and disease; understanding patient behavior and motivating behavioral change; exemplifying a professional physician role and behavior; demonstrating effective, compassionate physician–patient interactions; modeling facility in addressing social and cultural issues in health care; and demonstrating approaches to care that take into consideration health policy and economics. With its focus on the positive work that the institution is already modeling, AI inspires and motivates the community to reach its full potential.

Create a Reflective Community

Self-reflection is important not only for individuals but for institutions as well. It enables members to intentionally examine the professional and learning environments that they and their institution foster and promote. Institution-wide conversations about positive and challenging critical incidents—published in weekly newsletters or other public format—can promote open reflection about an institution’s learning and professional environment, allow acknowledgment of error, promote discussion of values, and provide an opportunity for the members of an institution to thoughtfully consider the moral ethos of their culture.

Medical training programs have employed a variety of organizational and theoretical frameworks as vehicles for increasing education in the SBS. These efforts, while important, are an incomplete solution. Attention to trainees’ learning environment, and their experiential learning in the informal curriculum, are also critical. The authors suggest that educators consider including learning experiences that draw upon and integrate both formal and informal curricular content and experiences. They provide examples of educational activities within a range of theoretical orientations that accomplish this integration. Examples illustrate how narratives, generated by trainees and other members of the academic community about personal experiences and perceptions of the organization’s professional culture, can be creatively integrated into the formal curriculum in a variety of contexts. This strategy promotes personal and organizational reflection and mindfulness, and reinforces the importance of lessons learned in the informal curriculum. This cyclical process promotes awareness of the individual community members’ roles in the creation of a culture conducive to learning and caring for patients.

The authors acknowledge Drs. J Satterfield, A. Schickedanz, R. Salazar, S. Adler, H. C. Chen, K. Hauer, D. Hughes, and G. Saba for providing contributions to the “Medical Education Methods Effective for Teaching Behavioral and Social Science” section. Funded in part by NIH Award R25AR060994.