Pearson, Nancy J. PhD; Chesney, Margaret A. PhD
In this article we describe the historical context and provide an overview of a program funded by the National Center for Complementary and Alternative Medicine (NCCAM) called the Complementary and Alternative Medicine (CAM) Education Project. The goal of this project was to incorporate CAM information into the curriculum of selected health professions schools. To carry out this initiative, competitive NCCAM grants were awarded to 15 health professions schools in the United States. The articles in this issue describe some of the barriers and challenges many of these projects overcame and the contributions that they made to the curricula in medical and nursing schools. The articles cannot do justice to the creativity and dedication that the project directors and their colleagues gave to these projects, which, in the end, exceeded NCCAM’s goals for the CAM Education Program.
In 1998, Public Law 105-2771 established the National Center for Complementary and Alternative Medicine (NCCAM) at the National Institutes of Health in response to public interest in complementary and alternative medicine (CAM)—defined in the law as health promotion, illness prevention, and healing practices that are outside what is considered to be conventional medicine. Specifically, the statute authorized NCCAM to conduct scientific research on CAM, train researchers, and disseminate authoritative information about CAM to the public and health professionals.
In pursuit of the part of its mission to disseminate authoritative information to health professionals, the center released a program announcement entitled “Complementary and Alternative Medicine (CAM) Education Project Grant” in 1999.2 The fact that this program announcement was among the first released by the new center reflects the importance placed on this part of NCCAM’s mission. The immediate goal of the program announcement was to encourage and support the incorporation of CAM information into medical, dental, nursing, and allied health professions schools’ curricula, into residency training programs, and into continuing education courses. An important longer-term goal was to accelerate the integration of CAM and conventional medicine. As such, this program announcement fulfilled a portion of NCCAM’s mandate to “study the integration of alternative treatment, diagnostic and prevention systems, modalities, and disciplines with the practice of conventional medicine as a complement to such medicine and into health care delivery systems in the United States.”1 This goal is also consistent with objectives stated in NCCAM’s first strategic plan to “incorporate insights and opportunities afforded by safe and effective CAM and conventional practices and facilitate coupling of effective CAM and conventional practices within a coordinated, interdisciplinary health care delivery system.”3
NCCAM funded a total of 15 grants that responded to this program announcement. They were funded in cohorts of five per year in 2000, 2001, and 2002–2003 (see Table 1). This education initiative then ended, with plans to evaluate its impact.4 The funded applicants were 12 medical schools, two schools/colleges of nursing, and the American Medical Student Association. The maximum direct-cost budget for each grant was $300,000 per year, with a maximum duration of five years. Fourteen of the grants were funded for five years, and one grant was funded for three years. The total investment by NCCAM was approximately $22.5 million.
Early CAM Curriculum Development
Before NCCAM’s development of its CAM Education Program initiative, there had already been significant activity in health professions schools (e.g., medical, dental, nursing, and allied health schools) to incorporate CAM information into their curricula, both in the United States and in other countries. This activity was likely attributable to emerging evidence that a significant percentage of individuals were using CAM therapies, either in conjunction with conventional therapies or in place of them, to treat a variety of health conditions.5 During the 1990s, several commentaries and research reports in the biomedical literature described the state of CAM in the curricula of health professions schools. In 1998, for example, Wetzel and colleagues6 surveyed 117 of the existing 125 U.S. medical schools and found that 64% offered some courses in CAM either as an elective or as part of a required course. However, they also found that there was great diversity in content, format, and requirements. Those same authors also cited efforts by the American Medical Association7 and the Association of American Medical Colleges8 to define and encourage medical student education in CAM by commissioning reports and by supporting CAM interest groups and workshops.
Throughout the 1990s and into the early years of the 21st century, discussion and debate continued about the best way to educate conventional health professionals about CAM therapies. In 2001, the British Medical Journal published an article by Owen et al9 with an accompanying editorial by Berman10 on CAM education in the United Kingdom. It is clear from these articles that a similar debate and discussion was occurring in the United Kingdom about how CAM education should be incorporated into health professions schools’ curricula. These authors discuss some of the barriers and challenges, such as the already very full curricula in most medical schools and, more importantly, the need to balance the disease-oriented technological approaches common in conventional medicine with the patient-oriented holistic approach characteristic of many CAM practices. Another important issue noted by these authors concerns the role of the conventional practitioners who are the beneficiaries of the CAM information in health professions schools’ curricula. What does this CAM education prepare them to do? Is their role to refer patients to competent alternative practitioners? Should they guide patients to evidence-based information about CAM therapies to help them make informed choices? Should they actually treat patients with CAM therapies? If the latter is the case, what additional training would be required?
In September 2002, Academic Medicine published several articles, commentaries, and research reports on complementary, alternative, and integrative medicine.11 Articles in this issue highlighted some of the successful medical education programs in complementary and integrative medicine such as the Program in Integrative Medicine at the University of Arizona College of Medicine.12 This description was balanced with commentaries from others who expressed concern about the lack of scientific evidence for many CAM therapies.13 During this period, schools of nursing were also exploring the best ways to incorporate CAM information into their curricula and to determine how to evaluate nursing competency in CAM.14,15
Activities of, Barriers to, and Contributions of the NCCAM Program
At the time others were beginning to develop CAM curricula in health professions schools, the NCCAM CAM education grants were funded. To facilitate sharing of ideas among the NCCAM programs located at different health professions schools and to be responsive to changes in the rapidly changing field of CAM, the center hosted annual meetings of the CAM Education Program directors and their senior staff, held each June in Bethesda, Maryland. These meetings accelerated the transfer of innovative ideas and lessons learned among the projects. In addition, these annual meetings were important in transferring information about progress achieved by programs funded during the earlier years to those programs that began later.
The series of articles published in this issue of Academic Medicine in part accomplishes one of the goals of the NCCAM CAM Education Program—that is, to disseminate to other health professions schools what this group has learned during the course of developing the education programs. In this sense, this series of articles provides an informal manual for other health professions schools that wish to introduce or enhance CAM and/or integrative medicine education in their curricula.
All of the curriculum-development programs that were funded through the CAM Education Program encountered barriers and challenges. Although the specific barriers may have differed at each health professions school, each confronted some resistance that had to be overcome. The specific nature of the challenges was influenced at least in part by the focus of the health professions school (e.g., internal medicine, nursing, family medicine, cancer therapeutics), the density of the existing curriculum, and/or the attitudes toward CAM of the course directors, deans, department chairs, and others who have authority over curriculum development. These barriers and challenges, and descriptions of how they were overcome, are discussed in more detail in the following articles.
One general solution that would help overcome these types of barriers could be the development of a standard curriculum for providing CAM information, or at least a description of content that must be included in a standard curriculum. Although the development of such a standard curriculum was not a goal of the CAM Education Program, the hope is that the experiences of these projects, including descriptions of the barriers and challenges they faced, the strategies to overcome them, and the record of their successes, will provide some useful information to those bodies who have the authority to develop guidance for health professional school curriculum content in the future.
Another challenge faced by many of the programs was the need to involve CAM practitioners. Although the program directors often had an interest in CAM or knowledge in one or two areas within CAM, they rarely possessed sufficient clinical experience in a broad array of CAM practices. Therefore, it was essential to engage CAM practitioners in the curriculum development because they have the necessary expertise regarding specific CAM practices. Different programs developed different models for this involvement, which are described in the following articles.
Current and Future State of CAM Curriculum Development
The term integrative medicine emerged just as NCCAM was being established. Indeed, a number of the 15 CAM Education Programs are described as integrative medicine rather than as CAM. Therefore, central to all curriculum-development activities in this program and future programs that NCCAM may support is the question of what integrative medicine really means and how this definition affects the education of conventional health care providers.
The current, lively discussion on this topic is a continuation of the debates and discussions about CAM and integrative medicine in the 1990s. Two publications summarize many of the salient issues. Bell et al16 argue that integrative medicine is not simply a blending of the best of CAM into conventional medicine but that it “represents a higher-order system of systems of care that emphasizes wellness and healing of the entire person (bio–psycho–socio–spiritual dimensions) as primary goals, drawing on both conventional and CAM approaches in the context of a supportive and effective physician–patient relationship.” The view of Snyderman and Weil17 is consistent with this general description of integrative medicine.
Furthermore, these authors suggest several ways to improve education in health professions schools and practice. Among these recommendations are that medical education should refocus on the patient as a whole, involve the patient as active partner, understand the benefits and limitations of conventional medicine, teach health care practitioners the fundamentals of CAM therapies, including current evidence or lack of evidence for their effectiveness, and encourage clinical research to test the efficacy of CAM therapies.
Finally, the Consortium of Academic Health Centers for Integrative Medicine, a group of more than 30 U.S. health professions schools, incorporates many of these tenets into its definition of integrative medicine, which is “the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, health care professionals, and disciplines to achieve optimal health and healing.”18 NCCAM’s view, as elaborated in its most recent strategic plan,19 is consistent with these definitions and states that integrative medicine should integrate “the most effective treatments for patients by combining both conventional and alternative approaches to address all aspects of health and wellness—biological, psychological, social, and spiritual.”
Given this near consensus about the principles of integrative medicine, these principles should be part of the curriculum in health professions schools, with the ultimate goal of achieving optimal patient care. Key to optimal patient care is the challenge of determining the level of evidence required to recommend a therapeutic approach as part of an integrative health care program. Given the lack of strong evidence of efficacy for many CAM therapies, there is some concern that integration is under way in spite of the lack of reliable, rigorous science to support the use of most CAM treatments. NCCAM’s view is that the speed of CAM’s incorporation into integrative medicine should not be driven by market forces but by the accumulation of scientific evidence for the efficacy of CAM therapies.20 Nonetheless, the recent estimate that 36% of individuals in the United States use some form of CAM for health reasons21 makes it critical that conventional health professionals be aware of these CAM practices and have authoritative resources to provide their patients about risks and benefits of these practices.
Another difficult question related to integrative medicine is whether conventional practitioners are at liberty to select only specific parts of CAM practices so that they more readily fit into conventional care, or whether they should assimilate whole CAM medical systems as practiced by CAM practitioners to obtain the maximum benefit to patients.16 A typical example is the common use of acupuncture in the United States, divorced from the holistic system of Oriental medicine involving herbs and other treatment modalities, of which acupuncture is only a part.22
This brings us to the current and future state of CAM curriculum development. Much of the more recent history of CAM’s introduction into the curricula of health professions schools, including data from the NCCAM CAM Education Program, is summarized in Chapter 8 (“Educational Programs in CAM”) of the 2005 Institute of Medicine report Complementary and Alternative Medicine Use in the United States.23 There are two recommendations from this report that relate to the CAM Education Program:
1. The committee recommends that health professional schools (e.g., schools of medicine, nursing, pharmacy, and allied health) incorporate sufficient information about CAM into the standard curriculum at the undergraduate, graduate, and postgraduate levels to enable licensed professionals to competently advise their patients about CAM.
2. The committee recommends that federal and state agencies, and private and corporate foundations, alone and in partnership, create models in research training for CAM practitioners.
The first of these recommendations is wholly consistent with the goals and the curriculum-development accomplishments of the CAM Education Program.
In this regard, the emerging goals from these CAM curriculum-development efforts are that conventional health care providers, as part of an integrative medicine environment, need to
* know how to ask patients about their use of CAM or integrative medical practices;
* be familiar with the most commonly used forms of CAM so they can discuss these practices with their patients who may be using them;
* be able to refer interested patients to reliable sources of information; and
* know how to obtain reliable information about the safety and efficacy of CAM or integrative medical practices.
As part of this integrative medical environment, educating patients about CAM is important, especially given the prevalence of self-care, which has been estimated to be just as prevalent as treatment provided by CAM practitioners.21,24 Thus, increased communication among patients, CAM practitioners, and conventional health professionals is vital to optimize patient care. However, in most cases, the CAM curricula and training provided in medical, nursing, and allied health professions schools is not designed to prepare conventional health practitioners themselves to provide care through CAM therapies.
Funding for these initial 15 CAM Education Programs ended in the spring of 2007. NCCAM will evaluate the program to determine the next steps, with a continued interest in supporting high-quality integrative medicine. At the same time, NCCAM hopes that the investment in integrative medicine made through this CAM Education Program will help sustain these nascent programs into the future. Although it is too early to determine the full impact of these programs, NCCAM plans to evaluate their impact on integrative medical education and is setting the groundwork for such an evaluation now. In addition, NCCAM plans to continue to provide a forum for discussion of CAM curriculum development by extending the annual June meetings at which CAM Education Program directors and invited guests can come together to discuss current themes and issues in this area.
Fostering Research Training for CAM Practitioners
Related to the second recommendation of the Institute of Medicine, and on the basis of the belief that CAM practitioners have a role to play in integrative health care and in determining the CAM content in conventional health professions schools, NCCAM has introduced several initiatives to provide research training to CAM practitioners. First, in response to the need to provide research information to CAM practitioners as part of their professional education, NCCAM initiated another curriculum-development program in 2004 to increase the research content in CAM practitioner training in accredited schools that offer doctoral degrees in a CAM practice (the CAM Practitioner Research Education Project Grant Partnership).25 Institutions that receive funding through this initiative achieve their goals in partnership with research-intensive institutions. Thus far, five schools that train CAM practitioners have received funding (see Table 2). The last group of applications submitted under this initiative is under review. This new group of CAM Education Program directors and their senior staff joined the representatives from the conventional health professions schools at the June 2007 annual meeting to take part in the dialogue about CAM education for health care professionals, both CAM and conventional. Finally, in partnership with The Bernard Osher Foundation, NCCAM has recently announced a career-development award with the goal of providing research training to CAM practitioners who hold clinical doctoral degrees in a CAM practice.26
An important longer-term goal of the CAM Education Program is to accelerate the integration of CAM and conventional medicine. This, in turn, will contribute to the growth of integrative medicine that is perhaps best defined by the statement of the Consortium of Academic Health Centers for Integrative Medicine16 quoted earlier. The ultimate goal is to train health care professionals to provide optimal care to their patients by working in partnership with their patients to take full advantage of all safe and effective approaches to promote health and to prevent and treat illness. CAM and conventional health care providers both need to participate in this effort. Educating conventional health care professionals about philosophies and approaches of CAM, as well as educating CAM professionals about the evidence basis of conventional medicine, will help make this possible.
The authors acknowledge the contribution of Dr. Neal West, former NCCAM program officer, who developed the NCCAM CAM Education Project initiative and guided it through its early years. The authors also are grateful to Dr. Richard Nahin for his helpful comments on the manuscript. Finally, the authors are indebted to Dr. Stephen Straus, first director of NCCAM, for his enthusiastic and crucial support of this initiative.
1 P.L. 105-277. Public Health Service Act: Subpart 5: National Center for Complementary and Alternative Medicine. SEC. 485D [287c-21] Purpose of the Center; Section C: Complement to Conventional Medicine.
5 Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. Unconventional medicine in the United States prevalence, costs, and patterns of use. N Engl J Med. 1993;328:246–252.
6 Wetzel MS, Eisenberg DM, Kaptchuk TJ. Courses involving complementary and alternative medicine at US medical schools. JAMA. 1998;280:784–787.
7 American Medical Association Council on Medical Education. Encouraging Medical Student Education in Complementary Health Care Practices. Chicago, Ill: American Medical Association; June 1997.
8 Muehsam PA. Alternative and complementary medicine special interest group. GEA Correspondent. Spring1997:10.
9 Owen DK, Lewith G, Stephens CR. Can doctors respond to patients’ increasing interest in complementary and alternative medicine? BMJ. 2001;322:154–158.
10 Berman BM. Complementary medicine and medical education. BMJ. 2001;322:121–122.
11 Complementary, alternative, and integrative medicine. Acad Med. 2002;77: 847–889.
12 Maizes V, Schneider C, Bell I, Weil A. Integrative medical education: development and implementation of a comprehensive curriculum at the University of Arizona. Acad Med. 2002;77:851–860.
13 Five commentaries on complementary and alternative medicine. Acad Med. 2002;77:869–874.
14 Halcon LL, Chlan LL, Kreitzer MJ, Leonard BJ. Complementary therapies and healing practices: faculty/student beliefs and attitudes and the implications for nursing education. J Prof Nurs. 2003;19:387–397.
15 Parkman CA. CAM therapies and nursing competency. J Nurses Staff Dev. 2002;18:61–65.
16 Bell IR, Opher C, Schwartz GE, et al. Integrative medicine and systemic outcomes research: issues in the emergence of a new model of primary health care. Arch Intern Med. 2002;162:133–140.
17 Snyderman R, Weil AT. Integrative medicine: bringing medicine back to its roots. Arch Intern Med. 2002;162:395–397.
18 Consortium of Academic Health Centers for Integrative Medicine Web site. Available at: (http://www.imconsortium.org
). Accessed May 30, 2007.
20 Nahin RL, Pontzer CH, Chesney MA. Racing towards the integration of complementary and alternative medicine: a marathon or a sprint? Health Aff (Millwood). 2005;24:991–993.
21 Barnes PM, Powell-Griner E, McFann K, Nahin RL. Complementary and alternative medicine use among adults: United States, 2002. Adv Data. May 27, 2004:1–19.
22 Kaptchuk TJ. The Web That Has No Weaver: Understanding Chinese Medicine. New York, NY: Congdon and Weed; 1983.
23 Institute of Medicine of the National Academies. Complementary and Alternative Medicine in the United States. Washington, DC: National Academies Press; 2005.
24 Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990–1997: results of a follow-up national survey. JAMA. 1998;280:1569–1575.