PART 1
Introduction
While taking ward rounds you examine Mr R aged fifty-five years on bed no. 5, and Mr S aged forty-eight years on bed no. 6, both the patients have similar symptoms and have been diagnosed as carcinoma of lungs. From physical point of view you have knowledge of human anatomy, physiology, and learning of pharmacology helps you to prescribe medicines. Yet you find that both the patients are reacting to illness and responding to the medical treatment differently. How do you explain these differences? Mr S is restless, gets irritated easily, is always complaining of other staff working in the ward. On the other hand Mr R is accommodating and is grateful for whatsoever care is given to him. They are not only patients of bed no. 5 and bed no. 6, but are two human beings with their unique personalities, abilities to cope with stress and varied family responsibilities. These differences in behaviour are due to one's own personality and reactions to illness. It is not sufficient to have knowledge about the biological and organic aspects of the disease only, it is important to understand the person having the disease and his psychosocial background.
Definition
The branch of science, which can help you in understanding your patients as unique individuals, is known as Behavioural Sciences. This term has been used to denote the study of human behaviour both of the individual and of groups of people, small or large. It emphasises on individual behaviour and on the application of such basic knowledge to medical and allied disciplines.
Thus behavioural sciences have become part of the undergraduate medical education all over the world. Though this course is fairly well-established in many developed countries, it is included in some medical schools in India also. The Indian Medical Council has recommended its inclusion in all the undergraduate medical schools. Behavioural Sciences draws upon various disciplines and sciences related to the study of human behaviour like: psychology, sociology, anthropology, economics and statistics (Fig. 1.1). Psychology is the study of human individual behaviour. Sociology is more about social and group behaviours. Anthropology deals with culture and natural history of mankind of different races and their development. Economics has to do with the distribution of scarce resources within a society. The statistics helps in testing hypotheses and measurement. The treatment to all these branches cannot be given at par in this book more concentration is given on the understanding of the individual patient.2
Need for Behavioural Sciences
The aim of this book is to help the students to develop an understanding of human behaviour, and its relationship with medical practice. The understanding of conceptual and methodological basis is required for subsequent clinical instructions. An understanding of human behaviour is desirable in most branches of clinical practice; it is especially important in medicine, psychiatry, community medicine, pediatrics and geriatrics. There are ample examples to illustrate the need for the disciplines of behavioural sciences (which mainly consists of psychology and sociology) to provide a systematic academic foundation in the preclinical period for these clinical subjects.
Developments in medical education have come about mainly as a response to scientific and technological advances made in the field of medicine. There is a growing danger that the student may become so preoccupied with the minutiae of the specialities and with the technologies of the laboratory that he loses sight of the patient as a “whole person”, functioning in a social context. Moreover little attention is paid to changes in community patterns of disease or to changes in the social functions of medicine. This has led some medical educators to search for a counter-balancing element to build into the medical curriculum. It seems that behavioural sciences can provide this element. They can have a significant effect on the outlook and attitudes of medical students, both through their subject matter (human behaviour and social processes) and through their central premise that the problems they deal with are susceptible to scientific investigation and explanation.
Behavioural Sciences can be of more direct medical relevance also. In medical practice the doctor's main concern is individual patient. Often one encounters differences in response to pain, illness, hospitalisation, and other stresses; the influence of personality and social class on illness. Patient's personalities and relationships may be important factors in the disease process and in medical care. A doctor also needs to communicate effectively with patients, their relatives, with colleagues-doctors, and nurses. He faces resistance to attitude and behaviour change in the context of preventive medicine—these are a few examples of everyday problems of medical care, which require the doctor to form judgement and make decisions based on an understanding of human behaviour and institutions. Biological training alone does not prepare a doctor to deal with such situations.
Furthermore, psychological knowledge can be valuable in developing the effectiveness of the student's and doctor's own cognitive processes. Clinical practice involves complex routines of observations, discrimination, and interpretation, acquiring and retaining factual information, of problem-solving and decision-making. There is an extensive body of psychological knowledge concerning these processes and the variables which influence them (e.g. the effects of fatigue, attitudes, and expectancy on accuracy of perception and recall); and it is believed that students can profit from awareness of these problems and of the principles underlying them.3
Culture as Determinant of Health
Culture is shared learned behaviour that is transmitted from one generation to another for purposes of human adjustment, adaptation, and growth. Culture has both external and internal referents. External referents include roles and institutions. Internal referents include attitudes, values, beliefs, expectations, and consciousness.
Culture is something that mediates and shapes virtually all aspects of human behaviour. It is the way in which human beings define and experience reality. It includes their sense of morality and personhood. These dimensions of human behaviour are not inborn but rather are shaped by the socialisation process. An ethno cultural group's language and its religion, economic, political, and social systems are institutional reflections of culture and help to shape the internal referents as part of a reciprocal or interdependent system.
As children are reared, they are conditioned directly and indirectly to think, feel, and act in certain ways. These ways constitute their reality. Their language helps to shape reality and is also in turn shaped by it. Culture is a critical determinant of human behaviour, to the extent that culture varies, human behaviour must also vary. Compare the two adolescent males grown up in two different places like one in North India and the second in down South, you would find that their differences in the appearance, food, dress, and rituals also produce differences in the way they think and define reality. The individual is the representative product of biological, psychological, social and cultural determinants. Figure 1.2 presents this conceptualisation of human behaviour.
The illness behaviour is also influenced by the cultural determinants, e.g. in many cultures males are not likely to cry or express pain or suffering, during an illness. If you are not aware of these determinants, then probably your assessment of that patient's pain and suffering will be biased.
Scope of Behavioural Sciences
Training in the behavioural sciences is essential for the appropriate education of physicians as major health problems of today can lead to premature death or disability. Cardiovascular disease, substance abuse, AIDS, cancer, and adolescent pregnancy are directly caused by risk-taking behaviour and can be prevented by people only by modifying their lifestyle and behaviour. Many diseases require major modifications of lifestyle to ensure benefits of therapy. The primary purpose of teaching behavioural science in medical schools is to prepare physicians to understand the role of social and psychological factors in the aetiology and course of disease. The knowledge can be applied to reduce the burden of disease by changing the patient's behaviour. Some other causes of illness stem from sociocultural forces, such as poverty, low socioeconomic status, and industrialisation. These factors are very common in developing countries, though they lie beyond the realm of the individual doctor-patient relationship; yet understanding these factors can help physicians plan appropriate medical services and preventive efforts.
The scope of behavioural sciences is envisaged in the following areas of medicine.
The Doctor-Patient Relationship
The clinical knowledge base now includes a large amount of research on doctor-patient 4relationships which has been demonstrated to be important to patient care outcomes. It includes information about the understanding of intimacy-relations of trust and power between doctors and patients, and how interpersonal influence works in doctor-patient transactions.
Effective interviewing techniques are among the most essential skills that all physicians need to learn. Many studies have demonstrated that physicians who fail to obtain accurate information may misdiagnoses or recommend inappropriate therapies. Examples of successful outcomes due to skillful inquiry provide useful stimulus for students to learn behavioural sciences.
Social Class and Health Behaviour
Social class is broadly associated with almost every indicator of morbidity, disability and mortality. Factors associated with lower social class increase susceptibility to illness and injury. Understanding specific risks and vulnerabilities associated with social status provides physicians opportunities for more effective communication and therapy, and for preventive initiatives.
Several investigators have demonstrated that disadvantaged social environments increase the risk of serious health problems especially in children and adolescents. One of the examples is the low birth weight child when reared in disadvantaged environment, has an increased prevalence of acute and chronic illness for as long as eleven years after birth.
Physicians often underestimate the extent to which the patients of lower socioeconomic status desire information. Such patients are often less expressive and less questioning than the better educated patients and physicians commonly give them less treatment relevant information.
Human Development: Life Cycle, Health and Illness
Physicians need to understand how life experiences at one stage of development influence later behaviour, susceptibility to illness, and use of medical services. Previous life experiences also modify physiologic and immunologic responses. Longitudinal studies of life span in humans have illuminated the cause-and effect relationships of early nutrition to later heart disease and the effect of early life stress on later immunologic response.
Psychophysical Relations
This is one of the most rapidly advancing fields is in the mind-body relationship. Parents with a child who is dying from leukaemia have markedly different cortisol and T-lymphocyte responses, depending on whether they can grieve openly or not. Those who cannot grieve have greater elevation of cortisol and more illness in the year after the death of a child than those who can.
Data from primate laboratories have demonstrated that about twenty per cent of monkeys are shy and withdrawn from birth, and if left on their own, grow up to have low status in the group. These studies not only demonstrate the biological basis of such behaviour but the possibilities of modification by early experience.
Children who are taught self-imaging (i.e. self-hypnosis) respond with greater secretory IgA in their pharynges than those who are not, and self-imaging has been shown to be as effective in treatment of migraine headaches in children as standard pharmacologic treatments.
There are marked individual differences in cortisol and neuroimmunologic response to stress from early life. Physicians need to recognise the mind-body relationship, which has been extensively documented. Physical disease cause behavioural changes. Psychological stresses cause physical changes.
Health and Illness Behaviour
Differences in behaviour account for much of the variation in the health of different populations. These include not only personal health behaviours such as smoking, diet, substance 5abuse and exercise but also exposure to environmental risks and interpersonal, work-related and community-related stresses. Risks to health are often inadvertent consequences of personal choices and routine activities. Understanding these risks and developing strategic approaches for intervention enhance physician's opportunities to assist their patients in leading healthier lives controlling many extremely serious risks to health and to life itself such as HIV infection depends exclusively on successful modification behaviour and exposure to risk.
The Impact of Social Support
Many studies show that the presence of social support, the quality of social networks, and the degree of participation in them have substantial effects on coping health status, and longevity.
The Importance of Self Efficacy
A large literature now attests to the importance of self efficacy in supporting social adaptation and health. The deterioration of frail elderly persons who move to new environments is often linked to their sense of loss of control. Haggerty et al (1993) have quoted experiments carried out in nursing homes, which show that increasing the elderly person's sense of control results in enhancement of health. Similar finding have been reported on patients with chronic pain, that experience of pain is less in patients who think controlling power is with the person himself (see Chapter 25). While there is still much to be learned, several areas of research converge in demonstrating the importance of a person's sense of control over his or her immediate environment.
The Hole of Self-Attention on Symptom Amplification
Numerous lines of investigation show how focussed attention on physical states amplify the intensity of experience and concern about health status (see Chapter 3). Understanding of this work has relevance for pain management and for understanding symptom prevention and response.
The Illness-Disability Perception
Disability caused by the illness depends on a range of factors that intervene between the occurrence of illness and disability. These factors include personal variables such as attitudes and motivation; aspects of the social context, such as opportunities for participation, stigma, and physical accessibility; and the health workers’ management of the initial condition over its longitudinal course. The understanding of these factors is crucial in the appropriate care of persons with physical impairments, the elderly, and individuals with chronic disease.
Adult Sexuality, Loss, Grief, Mourning, Aging, and Death These issues are concerned primarily with the interaction of psychologic and sociologic aspects of individual behaviour and need few specific examples to demonstrate their importance. Behavioural science seeks to understand the social organisation of the communities in which patients live, the institutions involved in the provision of medical care, and their influence on health.
Selye described the general adaptation syndrome and developed the general concept of stress and the neuroendocrine mechanisms involved, particularly the role of catecholamines and the steroids. Since that time, steady progress has been made toward working out step-by-step the biological mechanisms involved, whereby stress can lead to cardiovascular changes that cause heart attacks and stroke or have profound effects on the immune system for example, we still have a long way to go in learning the details of these mechanisms, but we know enough already to begin to see how behaviours such as smoking and high fat/high calorie diets, for 6example, affect these same mechanisms and exacerbate them and how exercise can ameliorate them. We also know that behavioural change leading to prenatal care, good nutrition, and immunisation will make the difference in improving our infant mortality rates. Furthermore, violence, teenage high-risk behaviours, and suicide are major cause of mortality and morbidity. Finally, we know that adherence to medication, especially in the adult and the elderly, remains a major problem in managing chronic diseases.
With chronic diseases such a major portion of modern medicine and so dependent on lifestyles, behaviour modification and coping strategies, health-promoting and disease-preventing behaviours become of great importance in the practice of medicine not only for their value in cost containment but also for the general welfare of our society.
SUMMARY
Behavioural sciences is the branch of science which can help you in understanding your patients as unique individuals. This term has been used to denote the study of human behaviour both of the individual and of groups of people, small or large. It emphasises on individual behaviour and on the application of such basic knowledge to medical and allied disciplines. Behavioural sciences draws upon various disciplines and sciences related to the study of human behaviour like psychology, sociology, anthropology, economics, and statistics.
An understanding of human behaviour is desirable in most branches of clinical practice, especially in medicine, psychiatry, community medicine, paediatrics and geriatrics. Behavioural sciences are of direct medical relevance, as in medical practice the doctor's main concern is individual patient. To understand variations in response to pain, illness, hospitalisation, and other stresses; the influence of personality and social class on illness, knowledge of normal range of behaviour should be known. Patients personalities and relationships may be important factors in the disease process and in medical care. A doctor also needs to develop communication skills to deal effectively with patients, their relatives, with colleagues-doctors, and nurses.
Psychological knowledge can be valuable in developing the effectiveness of the one's own cognitive processes. Clinical practice involves complex routines of observations, discrimination, and interpretation, acquiring and retaining factual information, of problem-solving and decision-making.
Culture shapes not only the normal behaviour but it also influences illness behaviour. Thus the patient's behaviour and his symptoms should be understood in their cultural context.
Thus the scope of behavioural sciences ranges from doctor-patient relationship to various aspects of health care such as, social class and health behaviour, developmental life cycle, psychophysical relations, social support, self efficacy, aging and bereavement.