Sierpina, Victor S. MD; Schneeweiss, Ronald MB, ChB; Frenkel, Moshe A. MD; Bulik, Robert PhD; Maypole, Jack MD
The challenges of introducing and teaching complementary and alternative medicine (CAM) in the curricula of standard health professions schools are worthy of the academic medical community's attention. A number of approaches describing the core curriculum and core competencies in CAM and integrative medicine have been published1–9 and are also the subject of other articles in this issue of Academic Medicine.10–16 However, a description of the best strategies to implement this training have not been detailed in any depth in the literature to date. The experience of the 15 recipients of the National Center for Complementary and Alternative Medicine (NCCAM) Education Program grants provides important lessons for other schools planning to introduce or expand their curricula on CAM.
In 2001, the National Institutes of Health (NIH) NCCAM instituted a funding program that awarded R25 grants, generally in the range of $1.5 million in direct costs during five years, to institutions to incorporate CAM education into their curricula; each institution's program was led by a principal investigator. The CAM Education Program involved 11 medical schools, two nursing schools, the American Medical Student Association, and one family practice residency program. Program directors met annually during the length of the funding and up to two years subsequently. After the 2005 NIH/NCCAM program directors' meeting, a supplemental survey to identify specific barriers and strategies to overcome them was mailed to each program director. This article is based on the responses from 13 out of 15 of the grantee institutions (87% response rate). One medical school was present at the director's meeting but did not respond to the survey, and one family practice residency program was not at the meeting and did not respond to the survey. Our purpose is to summarize the lessons learned, barriers encountered, and strategies to overcome those barriers across institutions.
Challenges and Barriers to CAM Education Initiatives
The introduction of any new content area into already full academic medicine or nursing curricula faces many common barriers, including competition for valuable course time, faculty and course committee buy-in, support from the institutional leadership, faculty development, resources, and long-term sustainability. These barriers have been encountered with the introduction of recent curricular innovations in geriatrics, HIV, and bioethics.17 In general, as noted elsewhere in this journal,12 the emphasis of these CAM curricular changes has been on teaching conventional health professionals about CAM approaches to health and healing, promoting an openness to discussing the use of CAM with patients, and integrating alternative approaches in considering therapeutic options. None of the participating schools had the goal of making expert CAM practitioners of learners.
Some of the challenges faced by allopathic educators in attempting to integrate CAM content into traditional health sciences programs are (1) overcoming faculty resistance, (2) finding time in an already full curriculum, (3) presenting a balanced yet evidence-based approach to assessing the efficacy of CAM therapies, (4) providing accessible and reliable reference resources, and (5) developing appropriate teaching and assessment methods. An overarching competency-based objective might be described as teaching students how to best advise and communicate to patients about the use of alternative treatments, including evidence, risks, benefits, and quality-of-care outcomes. Some concerns regarding teaching in the area are (1) the potential to overreach currently available data, (2) the possible prematurity of integrating alternatives into patient care that have not been rigorously tested, and (3) the problems of being seen as an advocate for nonconventional practices in one's own institutional context.18 In some cases, concerns about these issues have led to significant academic controversy.1,6,19,20
However, there are also benefits to be derived from the introduction of teaching about CAM to health science professionals. These include but are not limited to (1) the provision of basic knowledge about therapies commonly used by the public, including public health, safety, and efficacy issues, (2) improvement in communication skills about these therapies, (3) the use of CAM teaching as a model for enriching curriculum in cultural competency, spirituality, interdisciplinary education, and teamwork, (4) promotion of self-care through a more whole-person- and wellness-oriented approach, and (5) improvement in the ability of students to engage in critical thinking and to become self-directed, lifelong learners facing novel concepts and unfamiliar research literature.10,11,21–23
At the 2005 program directors' meeting, the 15 principal investigators presented the top three lessons learned at their own institution (List 1). They were also asked to identify the lessons learned regarding key barriers, and strategies related to them were collected in the supplemental survey (to which 13 responded). Six cross-cutting themes emerged as most important relating to the integration of CAM into curriculum.
1. Integration into the existing required curriculum: how CAM values, knowledge, skills, and attitudes are woven into existing courses and curriculum rather than being created as new courses.
2. Visibility: creating multiple forums in which CAM was presented, making this area easy to identify within the academic center's overall educational missions as well as with publicity, public presentations, and publications.
3. Faculty development: providing ongoing opportunities for faculty who are unfamiliar with CAM to learn about evidence, appropriate teaching strategies, and clinical applications.
4. Leadership: developing champions and support from administration for CAM education, servant leadership, and student involvement.
5. Accessible and reliable reference resources: online databases and Web sites permitting wide dissemination and access to CAM content areas.
6. Long-term sustainability: continuing CAM training and faculty development postfunding through institutional support of these activities.
These themes are “unpacked” in Table 1, and discussion of each follows.
Integration into the existing required curriculum
Health science professions education programs are widely perceived as “too full.” Although the reality is that the curriculum is always fluid, many important topics compete for classroom time. Yet, negotiating to add CAM material may be enormously time consuming. Most of the participants in this survey reported that they chose not to add an additional required course or courses but, rather, integrated CAM content into existing courses where appropriate. However, a few programs offered stand-alone CAM courses such as a CAM overview course, pharmacology and herbal medicine, and mind–body training. It is important to identify the goals of the CAM curriculum and to target existing courses for adding CAM content where the fit is seamless. It is also important to ensure that there is not undue repetition of the content material across courses; otherwise, students complain about redundancy. Establishing a theme committee sanctioned by the institutional leadership and curriculum committee chairs is one successful strategy. Schools also reported recruiting the curriculum deans as champions of the curricular changes. Principal investigators emphasized first offering low-risk, high-success curriculum activities with generally acceptable, reasonable goals that support related aspects of curriculum. Examples include pairing teaching of CAM content with curricular content on evidence-based medicine (EBM) and the relationship of patients' beliefs and practices to cultural awareness and competency.
Identifying places in the curriculum where conventional therapeutic approaches were questionably effective (e.g., chronic low-back pain, irritable bowel syndrome) provided openings amenable to the inclusion of alternative approaches. Course chairs were more likely to cooperate if they were offered help with delivering the teaching sessions and developing evidence-based syllabus content. Some examples of increasing CAM-related content from across the CAM Education Program schools included topics such as introductory history taking, including use of herbs and supplements; patient-centered interviewing; spirituality; cultural competency; critical-thinking skills in evaluating papers on CAM versus conventional approaches; communication about end-of-life or palliative care; nutrition; and the pharmacology of botanical medicines and nutritional supplements, along with their interactions with drugs. Course directors greatly appreciated that the CAM Education Program team members did the actual work of developing course materials, which lightened their own burden. All these activities were in keeping with the concept of servant leadership—a practical philosophy that supports people who choose to serve first and then lead as a way of expanding service to individuals and institutions.24
Bringing the CAM curriculum innovations to the attention of the academic faculty, students, and residents was seen as critical to facilitate the implementation and to ensure long-term viability. Many different approaches were used, including multiple presentations for students and residents as part of required courses; grand rounds; continuing education conferences; and interdisciplinary teaching. Including CAM practitioners in experiential demonstrations had a significant impact on students, as did organizing and promoting a student CAM interest group, which helped create grassroots peer support among the student body.
Easily accessed, Web-based information resources were essential to support the curriculum and patient care activities. Providing CAM clinical services in clinics and hospitals by some faculty together with CAM practitioners increased visibility and awareness among both faculty and students. Several sites held community events, mini-medical school presentations, or journal clubs, and they distributed information via in-house newsletters, the lay press, and media interviews.
The principal investigators agreed that faculty development efforts should be initiated early to develop a cadre of more knowledgeable faculty who could help in the implementation of such an institutional culture change. All programs responding to the survey saw faculty development as a key factor to success and sustainability. This is an essential dimension that must be addressed by other schools seeking to expand curriculum in this area.
This is because many faculty are not familiar with the broad range of CAM therapies and concepts, and some may be quite resistant to them. It was essential, according to several principal investigators, to assure faculty that CAM content experts can and will competently deliver subject matter. This was necessary because the CAM content was outside the expertise of the regular course faculty, who were, therefore, not well positioned to evaluate it. Offering this material using the generally accepted principles of EBM or evidence-based practice (nursing/allied health) was helpful both in getting faculty buy-in and in helping them accept and learn new content themselves. Training opportunities for faculty offered by most programs emphasized enhancing access to credible resources, educational materials, mini-sabbaticals, consultations, distance learning, continuing medical and nursing education, journal clubs, and other resources. Collaborating with CAM practitioners and CAM academic centers expanded the pool of faculty and reciprocally contributed to faculty development. Two programs (University of Michigan Medical School and University of Washington School of Medicine) each developed a yearlong, one-day-a-month faculty scholars program, which have been very effective in growing a cadre of faculty who are well informed about CAM. These faculty implement what they have learned in the faculty scholars program into their teaching, research, and clinical practice.
The integration of CAM content into conventional health science programs remains vulnerable if this integration is dependent mainly on the efforts of one or two champions. However, it does require the dedication of a committed, enthusiastic, and persevering champion to ensure that a programmatic change is developed and shepherded by a group of supportive faculty.25 Self-identified, interested faculty from the various CAM Education Program institutions became champions from within their own departments and roles in the academic center as the programs progressed. According to the survey, they needed emotional, social, and/or collegial support as well as information.
Thus, leadership became a preeminent value and essential need for all programs. Support from the dean's office was vital, as was support from course and curriculum committees. Servant leadership within existing curricular structures, as described previously, was valuable: faculty volunteered their time and effort to not only implement CAM course materials and to help clarify objectives for multifaceted CAM learning, but also to participate in activities above and beyond the CAM theme. Leadership also involved providing credible, balanced information at multiple venues, without being seen as a biased advocate. Leaders also took note of opportunities when existing curriculum was being changed or in flux. These cusps of change provided an opportunity in the curriculum-change process to lead and guide inclusion of relevant CAM materials. Leadership required finding and using CAM providers as teachers who could translate their discipline into language acceptable to students, residents, and faculty. Coordinating with faculty from different disciplines, including outside of conventional medicine, added additional layers of complexity.
Faculty liaison with student organizations such as the American Medical Student Association's Humanities in Medicine subgroup and locally driven student interest organizations was useful in engaging students outside the classroom. Working around student schedules was always challenging, but this was sometimes offset by offering honoraria or other rewards. Some programs offered students elective opportunities for self-reflection, self-care, stress-reduction, and relaxation classes and found that these students became ambassadors of such methods to their peers. Use of student leaders as advocates on the curriculum committee and other course-development committees was helpful in creating relevant design of course content and delivery.
Accessible and reliable reference resources
Most programs started with a limited information base to support their activities. As additional information was collected, programs provided library and server-based access to reliable, evidence-based information resources. To keep these CAM activities visible, and to promote regular access to these tools, it was vital to share these resources and links at as many presentations and teaching venues as was feasible. Most programs created their own CAM content Web sites with links to other reliable Web sites, databases, books, journals, and recent articles. Students, residents, and faculty were instructed in how to use those resources appropriately, sometimes through integration with electronic medical records and online patient education materials available in the clinics and hospital. Web-based cases and online learning modules were developed and are now easily accessible for those within and external to the host institutions. (See the article in this issue by Gaster et al12 for additional references, resources, and information on content.)
A general concern of the principal investigators was the issue of how to sustain their newly implemented CAM curricula after the resources provided by the NCCAM funding were gone. Though such strategies have been addressed in detail elsewhere,26,27 the key elements of sustainability are, predictably, an outgrowth of the other strategies described above. In particular, finding ongoing funding for support of faculty time and effort is essential. Other key factors and challenges are maintaining leadership activities of faculty and support at institutional, political, and administrative levels. Continuing faculty development, such as ongoing training; development of extramural research funding in related areas, such as mind–body or natural products; and continued evaluation of the educational efforts were anticipated to be significant predictors of future sustainability. Summarily, essential to sustainability is the “institutionalization” of programmatic elements of a CAM curriculum with adoption into the educational infrastructure and resources.
Conclusions and Recommendations
Given time and resource constraints, those interested in introducing new or enhanced CAM curricula into their medical, nursing, or residency programs can hopefully benefit from the experiences and lessons learned described in this article. The collective recommendation of the NCCAM-funded institutions is to follow the model of integrating this new material into existing curricula (the tapestry model), rather than developing stand-alone courses. However, the two nursing schools did have success in also introducing new, focused, stand-alone courses, The integrated approach helps to create increased visibility, develop faculty skills and buy-in, identify leadership, and provide access to credible resources. These approaches can help ensure that such curriculum will be developed in an efficient manner and will be sustained over time.
Other layers of challenge include creating a workable timeline for rolling out coursework in CAM. This can be done incrementally through electives, selectives, threaded themes, intersessions, intrasessions, and other segments of required coursework. Or, it can be part of a major revision in curriculum so that it is immediately integrated. Principal investigators agreed that it increasingly seems to be counterproductive to use the term CAM, because it has many connotations and different meanings for different people. Emphasizing the specific content itself instead of labeling it broadly is more likely to engender acceptance, particularly when aligned with general course objectives. The use of the term integrative was increasingly accepted and acceptable at medical and nursing programs as well as in allied health.
The principal investigators also identified a need to overcome feelings that if implementation is slow or incomplete, then it is a failure. More useful is taking the long-term view of this process as an evolutionary rather than a revolutionary change.
We anticipate that the approaches described here will foster broader support and acceptance when introducing CAM curricular materials, and that they will encourage greater mainstreaming of this content into standard health care curricula.
Thanks to Nickie Prelow for her assistance in manuscript preparation.
This article was supported by NCCAM R25 project grants awards to Boston Children's Hospital (AT000538), University of Texas Medical Branch (AT000586) and the University of Washington (AT000813).
The opinions offered here are strictly those of the authors and do not necessarily represent those of the NIH or NCCAM.
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