Nedrow, Anne R. MD; Heitkemper, Margaret PhD; Frenkel, Moshe MD; Mann, Douglas MD; Wayne, Peter PhD; Hughes, Ellen MD
An increasing number of Americans are employing complementary and alternative (CAM) therapies for health promotion and symptom management.1 CAM is a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine (http://nccam.nih.gov). The scope of CAM is vast, encompassing common examples such as chiropractic or acupuncture treatments for low-back pain to expanding areas of interest in mind–body techniques such as mindfulness meditation for coping with chronic illness and/or stress. In addition, CAM practitioners are providing care at increasing rates within conventional inpatient and outpatient settings.2,3 These trends provide a compelling rationale for better communication and cooperation between allopathic and CAM providers. This need was highlighted in the 2001 Institute of Medicine report, Crossing the Quality Chasm.4
There is little known to date about the benefits or obstacles to collaboration between conventional and CAM providers. In a small study, Lindahl and colleagues5 surveyed medical history assessment by three types of CAM providers (chiropractors, licensed acupuncturists, naturopaths) and allopathic family practitioners. Using a Delphi approach, the study found significant variation in the approaches used by the different providers, with little concordance as to what is important in a medical history. Fewer than 11% of questions survived as mutually important for all four disciplines. The congruent questions asked about demographics such as age and home address. Ultimately, the desired outcome of arriving at a mutually compatible patient-intake form for sharing clinical care was abandoned.
In a recent study of Israeli students enrolled in a CAM program, investigators found that 74% of CAM students felt they had difficulty in communicating with allopathic health care practitioners. Reasons included fear of being rejected and feeling inferior to allopathic practitioners.6 In response, Israeli researchers and educators implemented an educational initiative to CAM students in their final year of study, emphasizing evidence-based learning, patient-centered care, and communication skills with conventional health care providers. A precourse questionnaire and postcourse essays confirmed this training to be important, with CAM students feeling more empowered and more confident in their work and also in communicating with physicians. Findings such as these point to the need to enhance communication and, ultimately, collaboration between allopathic and CAM education institutions. Leaders within the 15 five-year CAM Education Project Grants (R25s) funded by the National Center for Complementary and Alternative Medicine (NCCAM) of the National Institutes of Health between 2000 and 2002, joined by national CAM organizational leaders, have been pivotal to move forward an academic agenda on education of allopathic learners in fields of CAM. For example, the Consortium of Academic Health Centers for Integrative Medicine, which meets semiannually to work together to promote integrative medicine education, research, policy, and clinical care (www.imconsortium.org), now includes 38 allopathic academic health centers within the United States and Canada. The education subcommittee of this consortium developed and disseminated to all academic deans of U.S. medical schools the core competencies medical students need to acquire in their training in the field of integrative medicine.7 Integrative (or integrated) medicine combines treatments from conventional medicine and CAM for which there is some high-quality evidence of safety and effectiveness (http://nccam.nih.gov).
The NCCAM funding initiatives also provided support for the development of new models of education collaboration. We describe exemplars of educational programs developed through this initiative below, and we conclude with suggestions for further areas of development in CAM/allopathic collaboration.
Four Examples of Collaboration
The University of Washington, Oregon Health & Science University, Tufts University School of Medicine, and University of California at San Francisco have each collaborated with academic institutions that train CAM practitioners for both didactic and experiential components of their programs. Each of the four programs took a different approach, but all resulted in positive outcomes and lessons learned for participating students, faculty, and institutions.
University of California, San Francisco/American College of Traditional Chinese Medicine
The interinstitutional collaboration between the University of California, San Francisco (UCSF) and the American College of Traditional Chinese Medicine (ACTCM) began in fall 2001, when a pilot “exchange” elective was launched for first-year health professions students from both schools. The goal was to create a collaborative learning experience in which students from both institutions could share their experiences of becoming healers, teach each others tools of the trade, and develop mutual respect and understanding.
This popular, case-based elective has been held annually since its inception, with 15 to 20 students from each institution enrolling each year. Participants reported gaining greater understanding of each other's systems after taking histories, performing physical exams, and formulating management plans for real and virtual patients together, as documented in qualitative evaluation of the elective.
Balanced participation by both schools has helped create a sense of parity that has been essential to the success of the elective. When, by chance, one year more ACTCM than allopathic students enrolled, they felt that medical students were not equally valuing the class.
Faculty has described this “exchange” as a valuable experience as well. After learning more about traditional Chinese medicine (TCM), a UCSF gynecologist who helped facilitate a session on infertility reconsidered her previous recommendation to patients to avoid all herbs prescribed by their TCM practitioners.
There have been logistical challenges to this elective. Although students expressed an interest in expanding this exchange throughout all four years of their professional education, because of respective class and exam schedules it was not possible to find times that fit into in each school's academic calendar.
The connections formed by faculty and students from each institution have led to new and productive collaborations. A senior ACTCM faculty member was instrumental in helping the first TCM practitioners become credentialed to practice at UCSF. Two UCSF Osher Center faculty now serve on the advisory committee of and will teach in ACTCM's new doctorate in acupuncture and Oriental medicine (DAOM) program, which began in fall 2006. DAOM students from ACTCM will have the opportunity to observe and work with licensed acupuncturists at UCSF's Osher Center community practice sites.
Tufts University School of Medicine/New England School of Acupuncture
In 2001, the Tufts University School of Medicine (TUSM) initiated a partnership with the New England School of Acupuncture (NESA) to enhance CAM content in medical school courses. The primary aim of this program was to integrate CAM knowledge and awareness into the allopathic medical curriculum. This collaboration is somewhat unique among the NCCAM-supported programs as the CAM partner (NESA) maintained an active, evidence-based research program that included Oriental medicine (OM) faculty with basic knowledge of evidence-based principles. An informal collaboration had existed previously through faculty exchanges between institutions, including TUSM's former dean of education serving on NESA's board of directors and NESA faculty lecturing in TUSM courses. Within this expanded, formal collaboration, NESA faculty contributed to TUSM program via three interrelated initiatives.
The first of these was the development of and improved access to NESA's OM library for TUSM faculty and students. NESA's Kelly Library hosts the largest journal collection of any OM school in the country. The Kelly Library has converted its catalog of article holdings to an electronic system using the Library of Congress machine-readable cataloging format. This enables TUSM faculty and staff to electronically access and search Kelly Library's journals database. The director of NESA's Kelly Library, who is also a licensed OM practitioner, provides seminars and training to TUSM faculty and students regarding evidence-based medicine searches of OM literature.
A Web-based curriculum outlining the fundamentals of OM and the scientific evidence regarding its efficacy and safety has also been developed. In addition to writing content that summarizes the philosophy and clinical practice of OM modalities (e.g., acupuncture, herbal medicine, tai chi), NESA faculty also wrote more than a dozen evidence-based summaries outlining the clinical and mechanistic evidence available regarding the application of a specific modality of treatment for a specific biomedical condition. Modules were consciously chosen to reflect examples for which OM research evidence is promising (e.g., tai chi for cardiovascular health) but not yet demonstrably effective (e.g., acupuncture for smoking cessation) and examples where the evidence is incomplete and inconclusive (e.g., acupuncture for stroke rehabilitation). Modules articulating the challenges of studying complex OM interventions using standard research design (e.g., issues related to valid sham acupuncture controls, and standardized versus individualized treatment protocols) were also developed.
Finally, elective clinical OM externships and research opportunities for advanced TUSM students to shadow acupuncturists and herbalists at NESA clinics throughout the greater Boston area have been created. TUSM students were also partnered with NESA research faculty in the development of evidence-based reviews of select topics. Examples of these projects integrated into the TUSM Web-based curriculum are The Use of Acupuncture for Menopause Related Hot Flashes, The Neurological Basis of Acupuncture Analgesia, and Acupuncture as an Adjunct for Breast Cancer.
These and other related activities stimulated and laid the foundation for a number of additional collaborative endeavors that are currently underway. Three new initiatives include (1) a joint TUSM–NESA master of science in pain research, education, and policy (PREP), (2) shared grand rounds between TUSM interns and NESA students at a family medicine clinic where both groups of students undertake the internship, and (3) the TUSM department of family medicine currently requiring all students rotating through this component of the curriculum to personally experience one CAM modality, such as tai chi, yoga, acupuncture, chiropractic, or massage therapy treatment.
Oregon Health & Science University/Western States Chiropractic College, Oregon College of Oriental Medicine, and National College of Natural Medicine
Portland, Oregon, has the distinction of housing academic institutions of allopathic medicine (Oregon Health & Science University [OHSU]), chiropractic (Western States Chiropractic College [WSCC]), Oriental medicine (Oregon College of Oriental Medicine [OCOM]), and naturopathy (National College of Natural Medicine [NCNM]). The first collaboration started as a research project in 1989 between WSCC and the family medicine department of OHSU around the care of patients with low-back pain. These efforts grew, leading to the pivotal event in research collaboration occurring between 1999 and 2000 when OHSU, with the three schools above, along with Kaiser Permanente, were successful in securing two, five-year NCCAM P-50 Center awards for research around neurological and craniofacial disorders. The first of these, received in 1999 and called the Oregon Center for Complementary and Alternative Medicine in Neurological Disorders, received $7.8 million, setting up an infrastructure among the four above schools for collaborative research, and funding postdoctoral research fellowships. The second P-50 Center grant, obtained in 2000, with a similar financial award and research scope and entitled the Oregon Center for Complementary and Alternative Medicine Research in Craniofacial Disorders, included Kaiser Permanente and the Oregon School of Massage, in addition to the above schools. This infusion of research dollars into integrative medicine solidified the research development in all four Portland academic institutions.
The stage was then set for the 2002 NCCAM CAM education award to develop a curriculum in integrative medicine for OHSU medical students. Nearly a third of the funding was awarded to WSCC, OCOM, and NCNM, which train doctoral-level CAM practitioners, for those institutions' participation in the curricular development. Again, this financial infusion built on the previous research funding strengthened the relationships among the faculty of all four schools. The collaboration involved frequent group meetings where faculty developed not only shared research, but also shared education. Eighteen hours of required curriculum in integrative medicine as well as several elective courses have been introduced to OHSU medical students between 2002 and 2006, and new, related curricula have been developed in the physician assistant program, the dental school, the school of nursing, and school of pharmacy. The annual distinguished lecture on a CAM-related topic has grown to over 500 attendees. A case-conference-style CAM grand rounds rotates between the campuses, electronic libraries are shared, and faculty of all four schools reciprocate in each institution's educational work through lectures, workshops, invited guest lectures, and conferences.
In 2004, with the collaborative development of a 30-hour online introductory educational module in CAM, institutional leaders believed it was appropriate to solidify the relationship between the four academic institutions; thus, a memorandum of understanding was developed and signed by the presidents of the three Portland academic institutions that train CAM practitioners and the dean of academic affairs at OHSU, initiating a new organization, the Oregon Collaborative for Complementary and Integrative Medicine, referred to as OCCIM (pronounced “awesome”). An integrative medicine fellowship within OHSU's family medicine residency was added in 2004 as well. Faculty status was granted to members from each CAM school to allow an integrative medical clinic to officially open in 2005.
The collaboration has not been without challenges, but fruitful lessons have been learned by the participating institutions. The number of OHSU faculty trained for research, education, or clinical work in integrative medicine have only minimally increased in the past five years, as grant funding has been given externally to CAM institutions, not internally for faculty development or to recruit additional faculty with integrative medicine training. Having CAM practitioners on campus teaching about CAM has not had a significant impact on OHSU's culture. Attitudes held by faculty at OHSU are largely unchanged by these research, educational, and clinical initiatives, as serial qualitative interviews have demonstrated.
University of Washington School of Nursing/Bastyr University
The University of Washington School of Nursing (UW-SON) partnered in 2002 with Bastyr University, a leader in the natural health sciences and natural medicine, to enhance University of Washington (UW) faculty knowledge regarding CAM use. At that time, the UW School of Medicine had also received an NCCAM CAM education award to partner with Bastyr University. However, this effort was focused almost exclusively on the education and training of medical students and the development of resources for medical practitioners. The UW-SON opted for an alternative approach to enhancing CAM curricular change—namely, the provision of CAM learning experiences for tenure-track faculty. This was accomplished by taking advantage of a summer enhancement program developed and offered by Bastyr University to UW medical students. Selection of UW-SON faculty for the summer program was based on their responsibilities for undergraduate and graduate nursing courses. Twenty UW-SON faculty have attended the summer program (called CAM camp) in four years, and the implementation of CAM-related content in required nursing courses has increased.
Additional outcomes of the educational collaboration include the creation of a series of brown-bag lunches focused on CAM modalities, provided to UW-SON faculty by Bastyr University faculty and CAM practitioners in the community. Results of these collaborations include the submission and eventual funding of a planning grant to create an international center for CAM in women's health research with Ewha Womans University School of Nursing and Oriental Medicine University in Iksan, South Korea, the development and U.S. Health Resources and Services Administration funding of a CAM certificate program in nursing, and the submission of a collaborative R21 research project (currently under review).
Recommended Future Directions for Academic Health Professions and CAM Collaborations
On the basis of the experiences of faculty from the four national institutional collaborations we have discussed, three potential issues have emerged: credentialing CAM providers at allopathic health professions schools, faculty development at allopathic medical schools, and cultural sensitivity.
Credentialing CAM providers
The credentialing of CAM providers may provide one avenue for further collaboration between allopathic and CAM institutions. It is increasingly common for allopathic educators to be given credentials and faculty status at academic institutions that train CAM practitioners; for instance, a nursing school might have a clinical faculty member who has a secondary appointment at a school of massage therapy. However, it continues to be unusual for chiropractors, naturopaths, and doctors of acupuncture and Oriental medicine to receive privileges and/or faculty status at conventional academic health professional institutions.8 For allopathic academic health professions institutions that are planning to partner with academic institutions that train CAM practitioners, it is important to have a policy in place regarding credentialing. As an example, OHSU limits medical staff membership to individuals with an MD, DO, or PhD. CAM practitioners are given privileges through a supervised faculty status, similar to dieticians, social workers, nurse practitioners, or physician assistants.8
A common way to provide information about CAM to health sciences students is to have alternative providers present in formal, evidence-based courses or didactic activities. Curricular content in CAM has been an excellent platform from which to analyze and rank evidence-based complementary medicine and to emphasize how to evaluate the evidence regarding allopathic medical therapies. However, problems can arise from differences in education backgrounds, styles of presentation, and content. One strategy employed by several of the NCCAM-funded programs was to have allopathic and CAM educators work closely together before content delivery. On the basis of experiences of the R25 programs, several suggestions emerged, including (1) careful review of all handouts before the presentation and/or (2) arranging a practice session preceding the first presentation for an alternative provider if mutually desirable. The time spent in this mentoring process can result in a more positive experience and a more sustainable curricular enhancement.
Collaboration between CAM providers and allopathic practitioners on education initiatives such as the programs described above requires cultural sensitivity. The past decade has seen a marked increase in educating conventional health care practitioners about the need for cultural sensitivity in the clinical arena.9 This same skill set is needed when interacting with CAM practitioners and educators. Most academic health professions faculty lack formal training in the philosophical and scientific underpinnings of CAM therapies.10 CAM models have been based on tradition, which the practitioners hold in great respect and esteem. Questions of credibility, if not handled well, not only undermine the presentations, but may also fuel antagonism between conventional and CAM providers.
There are real benefits to be gained at both the institutional and individual levels from educational collaboration between allopathic academic health professions institutions, CAM providers, and institutions that train CAM practitioners. We have outlined the need for increasing collaborations, including cultural sensitivity in working together, identifying specific recommendations and challenges likely to emerge. Issues such as faculty appointments and allotment of required curriculum for CAM topics are likely to remain controversial. Financial remuneration did not arise as a factor in the collaborations we have discussed; however, this issue may arise in the future. It is anticipated that the collaborations fused through the NCCAM CAM education program mechanism will be sustained beyond the funding time frame.
This article was supported by the following grants from the National Center for Complementary and Alternative Medicine: Oregon Health and Science University (001173), University of Washington School of Nursing (001240), University of Texas (000586), Tufts University School of Medicine (000714), University of North Carolina (000540), and University of San Francisco (000500).