APS Observer - October 2000 (Volume 13, Number 8) 'Several Things Went Wrong' The following is adapted from comments by APS Fellow and Charter Member John Kihlstrom, who served on the NRC committee. Several things went wrong in the report process. One was procedural. There just wasn't much involvement by social and behavioral scientists, aside from labor economists, perhaps. I think there were only two behavioral and social scientists on the Committee - and we were both psychologists (in fact, we were both Penn PhDs!). The Committee didn't have internal input from other social sciences, such as sociology and anthropology, or even political science, who have an interest in health and health care. Moreover, the Committee didn't receive much input from the outside, in terms of "public comment". [APS Executive Director] Alan Kraut made a powerful presentation to the committee, representing psychology, but so far as I am aware, no other psychology organization played any role in the committee's deliberations; nor did professional societies representing other behavioral and social sciences. This committee meets every couple of years, and the next time it meets the associations representing the behavioral and social sciences ought to have their ducks in a row. A related problem was organizational. The committee noted the paucity of data on behavioral and social scientists involved in research on health and health care, and I underscored this problem in my dissent. The fact is, while it can be assumed, almost by definition, that biomedical scientists are involved in research relevant to disease and medicine, an interest in health and health care can't be assumed for psychologists (who might study speech perception in bilingual children), sociologists (who might study race relations in high-school cafeterias), demographers (who might study immigration from Eastern Europe), and anthropologists (who might study kinship patterns in the South Pacific). But there are psychologists, sociologists, demographers, and anthropologists who study health and health care, and economists who study health economics, and there are political scientists who study the formation of health policy and health care. The National Institutes of Health (NIH) just doesn't have a good idea who they are. Moreover, the committee labored under a false dichotomy between basic and applied research. Within psychology, it sought to exclude clinical psychologists from consideration, on the grounds that clinical psychologists were engaged in the provision of mental health services, rather than in research. But many clinical psychologists do research, and many of them are important contributors to health psychology. In addition, there are interdisciplinary fields, such as health services research, that were also pretty much excluded from consideration, in part, at least, because these fields come under the auspices of the Agency for Health care Research and Quality and the Health Resources and Services Administration, rather than NIH. But it's in precisely these areas - studying the costs and benefits of health care, access to health care services, the quality of services, and the impact of changing organizational forms in the very dynamic environment of contemporary health care-that we need more behavioral and social scientists, and more interdisciplinary efforts. Studying the health care system shouldn't be just a matter of toting up costs and benefits on some accountant's ledger. Health care research should be driven by, and contribute to, theories in the behavioral and social sciences, just as research on diseases such as cancer and HIV/AIDS is driven by, and contributes to, theories in the biomedical sciences. Related to this was a committee perspective which I call 'physician-focused.' Almost without exception, NIH is run by physicians for physicians, so when the committee looked at things like clinical research, or clinician-investigators, its focus was almost entirely on medicine and physicians. The report attempted to exclude clinical psychologists from consideration, ostensibly because so many of them are engaged in the direct provision of services, but also called for increased efforts to train and retain physicians in the clinical research workforce. It is as if, ultimately, health and health care were solely the province of physicians. Even nursing research didn't get much attention in the report. Frankly, the policy of redirecting physicians into research seems misguided. Physicians consider themselves to be the only professionals who can provide the full range of health care services. There aren't enough of them, at least in many areas of the country, and in some specialties such as primary care and family medicine. At the same time, the American Medical Association carefully controls the number of seats in American medical schools, with an eye to the market for health care services, resulting in the recruitment and increasing numbers of foreign medical graduates to practice in the United States. And then we're supposed to divert an increasing proportion of physicians into research? It seems like a bad use of expensive medical training. If people want to do research, they should get PhDs, not MDs. And if MDs want to do research, they should collaborate with PhDs who have the training and skills to carry it out. That way, everybody would do the work for which he or she is trained. A third problem was methodological. The report is based on a highly abstract analysis in terms of labor economics. There's an overproduction of PhDs in the behavioral and social sciences, and so the committee concluded that the nation didn't need any more of us. But that's not the point. The point is how many behavioral and social scientists are doing work related to health and health care. And there aren't enough. What the committee should have done, and failed to do, was to call for a redirection of training and resources within the behavioral and social sciences toward health and health care. This is the main thrust of my dissent - that the committee failed to consider the need for increasing the number of behavioral and social scientists devoted to research on health and health care. A fourth problem was conceptual. The fact is that most physicians think of the behavioral and social sciences as not sciences at all, but as something to do until the real doctor comes along. We have a health care environment that is dominated by the machine and the pill - advanced diagnostic methods like MRI, and medications for everything. In such an environment, it's natural for people to discount the role of behavioral, psychological, social, and cultural factors, and emphasize biological processes. Two anecdotes from the committee's discussions illustrate the point: One committee member who suffered from stomach ulcers was greatly impressed when his gastroenterologist showed him a culture slide full of helicobacter pylori. That's where his ulcer came from, in the traditional medical view, and there's a medication for that; problem solved. But work by Bruce Overmier and others has clearly documented the role of stress, in interaction with h. pylori, in causing ulcers - it's a genuine psychosomatic effect. But this person wasn't interested in the role of stress in disease, or in reducing the amount of stress in his life - he was just interested in getting rid of the bugs in his gut, figuring that that would take care of everything. Another time, I was discussing the importance of compliance with medical regimens, outlining the potential significance of research on illness cognition by Howard Leventhal and his students, and work on extrinsic and intrinsic motivation by Judith Harackiewicz, Carol Sansone, and their colleagues. Compliance is a big problem in both prevention and treatment: you can develop all the pills you want, but then you have to get people to take their pills. And it's a behavioral problem, mediated by cognition, motivation, and affect. But another committee member, when confronted with the problem of compliance, retorted that "We'll make a pill for that, too!." It was a good joke, I suppose, but frankly I don't think he was entirely in jest. There are trends within psychology itself that aid and abet this tendency among physicians. Between behavior genetics, evolutionary psychology, and brain imaging, we're going through a period of intense interest in reductionism in psychology. In a recent article in the APS Observer, a prominent psychologist was quoted as saying that psychology was no longer a social science, but was now a life science - meaning, of course, that it is a biological science. As if psychology was just something to do until the neurologist comes; as if being a biological science should be something we aspire to, and being a social science should be something we outgrow. Of course, psychology has connections to biology: the brain is the physical basis of mind, after all. But psychology has, or should have, equally strong connections to the social sciences. Humans are social beings, and our thoughts, feelings, desires, and actions take place in expressly social contexts. So psychology needs to connect itself up to the other social sciences, as well as down to the other biological sciences. Because, in the final analysis, it's both a biological and a social science. This either/or, this-not-that thinking is very dangerous for a field as broad as psychology. We see the problems of psychology in general reflected in the current state of health psychology, which is almost totally dominated by the problem of stress and disease. Now, psychosomatic interactions are among the most interesting problems in psychology. Psychologists should be connecting with the biological sciences, and there's a tremendous amount of interesting work going on in fields like psychoneuroendo-crinology and psychoneuroimmunology. When the committee calls for greater involvement of the behavioral and social sciences in interdisciplinary research, they mostly mean involvement in biomedical research. But interdisciplinary research can also involve the individual and social levels of analysis, without involving the biological level. The simple fact is that biology doesn't offer us any solutions to compliance and many other problems of individual health and illness behavior. It doesn't offer us any solutions to the interpersonal and organizational problems created by the profound changes we're experiencing in the health care system. And it doesn't offer any solutions to the problem of providing adequate health care in a multicultural society like the United States, where health care consumers hold such a wide range of tacit theories of health and illness. These are all behavioral and social problems, and they have to be approached at the individual and societal levels of analysis. Psychology is a social science as well as a biological science, and we also need to be reaching out to the other social sciences, like sociology and anthropology, in our work on health and health care. Kihlstrom expressed strong dissenting views on the committee's recommendations; his views were included as an addendum to the report. The full text of his dissent can be read on the National Academy Press Website at http://www.nap.edu/books/0309069815/html/101.html. The full article on which these comments are based can be read on the web site of the Institute for the Study of Healthcare Organizations & Transactions at http://www. institute-shot.com/More_on_training _ health_researchers.htm.