Gaster, Barak MD; Unterborn, John N. MD; Scott, Richard B.; Schneeweiss, Ronald MB, ChB
Dr. Gaster is associate professor of medicine, University of Washington School of Medicine, Seattle, Washington.
Dr. Unterborn is assistant professor of medicine, Tufts University School of Medicine, Boston, Massachusetts.
Mr. Scott is manager of education programs, Osher Center for Integrative Medicine, University of California–San Francisco, San Francisco, California.
Dr. Schneeweiss is professor of family medicine, University of Washington School of Medicine, Seattle, Washington.
Correspondence should be addressed to Dr. Gaster, General Internal Medicine Center, UW Medicine, 4245 Roosevelt Way NE, Seattle, WA 98105; telephone: (206) 598-3575; fax: (206) 598-5952; e-mail: (firstname.lastname@example.org).
Complementary and alternative medicine (CAM) is a broad term that encompasses a wide range of healing therapies and practices. A large number of disparate CAM modalities are currently being used in the United States today.1 Health science educators setting out to incorporate knowledge about CAM into their curricula thus face a daunting challenge: how to identify a concise set of high-quality CAM content from such a complex and diverse field. Such an undertaking is especially difficult given the need to fit CAM content into health sciences curricula, which are already full and under pressure from many competing priorities.
Between 2000 and 2002, the National Center for Complementary and Alternative Medicine (NCCAM) hoped to address this problem by awarding education grants to 12 medical schools, two nursing schools, and one foundation to develop CAM education initiatives. All 15 institutions individually addressed the challenge of how to select quality CAM content. Via interviews and a survey of the educators who worked on these projects, we have drawn togetherthe individual experiences of these institutions in meeting that challenge. Following is a summary of the principles which these programs found most useful when selecting quality CAM content for health sciences curricula.
Curricular content about CAM can be divided into broad foundational skills and specific content areas. Introductory foundational principles are generally taught before specific content and are designed to give students a framework for future learning. Such principles include understanding the terms CAM and integrative medicine, understanding why patients use CAM, learning how to ask about and discuss CAM with patients in a nonjudgmental manner, and understanding the basic tenets of alternative healing systems, such as traditional Chinese medicine and naturopathy.
The concepts of patient-centered communication and the biopsychosocial approach to patient care, now widely accepted as being at the core of medical education,2–4 provide a solid basis for incorporating these CAM-related foundational skills into the curriculum. Several modular examples of how such principles can be taught are available in electronic form5–8 and can guide educators seeking to provide students with an understanding of the basics of CAM and a groundwork on which more specific knowledge can later be added.
Criteria for Selecting Specific Content
From discussions with educators at the institutions that have implemented NCCAM education projects, three questions emerge as central to the decision of which specific CAM therapies students should be taught: (1) is there significant scientific evidence for a therapy's efficacy or harm? (2) is there evidence that a therapy is being widely used by patients? and (3) does a therapy have the potential to treat a medical condition for which conventional medical approaches are lacking? Generally speaking, specific content needed to meet at least one of these three criteria to be considered for inclusion into a CAM curriculum. Topics with all three attributes were considered the most important to include in a curriculum.
Teach what works and what is harmful
Scientific evidence is central to health care and to medical education, and CAM must be held to similar standards.9,10 The evidence for or against the efficacy and safety of CAM therapies must be at the center of choosing what to teach.
Focusing on the evidence is especially important given the increasing number of high-quality studies of CAM therapies which are now being published. Whereas some of these have been positive,11,12 others have been negative,13,14 highlighting even more the importance of teaching students the science behind CAM. Such education about evidence is particularly important for dietary supplements, because the U.S. Food and Drug Administration (FDA), the usual federal body on which we rely to evaluate the efficacy of medicinal therapies, does not routinely perform this function for dietary supplements. Instead, under the Dietary Supplement Health and Education Act, the FDA's responsibility lies in taking action against unsafe dietary supplement products after they reach the market.15
Beyond gaining awareness about what works and what doesn't work in CAM, students must also learn the evidence that suggests which CAM therapies can be harmful. An example for potential harm is the very strong interaction between St. John's wort and many commonly used drugs.16 Supplements such as this have a high risk of hurting patient and are, therefore, very important for students to learn about.
Although those who study CAM therapies face many challenges, such as variability in herbal extract formulations or difficulty in blinding acupuncture interventions, such challenges can be overcome,17 and the evidence gleaned from such research should be used to guide education about CAM.
Teach what patients are using
Students should be taught societal CAM-use patterns so that they have a basic understanding of the CAM treatments their patients will be using. Such an understanding will give students better insight into the care their patients may be seeking elsewhere and will also better prepare them to answer their patients' questions about such treatments.18 For example, the dramatic growth in the use of dietary supplements seen in the latter part of the 1990s has now stabilized rather than receded,19 and students need some knowledge of some of these supplements that are so widely used.1
Another specific example of CAM which is increasingly being used by patients is mind–body techniques such as relaxation and meditation.1 Many education programs have recognized the potential for such self-care techniques to potentially reduce student stress20 and possibly prevent professional burnout.21 As a result, many have developed experiential mind–body electives to teach students more about these techniques, with the dual purpose of helping the students now and, possibly, their patients in the future.
Teach which medical conditions are most appropriate for CAM therapies
Some conditions are more appropriately treated with CAM than others. CAM therapies for conditions that are not well addressed by conventional medicine are more justifiably integrated with conventional care. When deciding what CAM to teach, therefore, educators should emphasize CAM therapies which have evidence for successfully treating conditions that allopathic medicine lack effective therapies.
For example, although there is little role for CAM in the treatment of acute appendicitis, the potential role for CAM as part of a multifaceted approach to the treatment of irritable bowel syndrome or fibromyalgia is clearer, because these are conditions for which conventional approaches lack efficacy and safety.22,23 Menopausal symptoms could also be included in this category, given safety concerns with conventional approaches,24 as could the treatment of depression, given the resistance among many patients to try standard antidepressants.25 Knowledge about potentially effective CAM therapies for such conditions could have a significant impact on patients' health and, thus, should be considered as more important for students to learn about.
Tools for the Future
Regardless of how much content is provided in a curriculum, science will evolve and questions will change. It is, therefore, of the utmost importance to provide students long-lasting tools for self-learning about CAM: (1) where they can find reliable information about CAM, and (2) how they can best search and interpret the literature to assess the results of CAM research.
Finding reliable reference resources
Ten years ago, there was much less interest among conventional health practitioners in learning about CAM, and there was also a dearth of high-quality research published about CAM.26 As a result, it was difficult to make good, evidence-based recommendations about CAM therapies and to find well-recognized reference works on the topic. In the past decade, however, practitioner interest in CAM has increased, the amount of CAM clinical trial data has expanded, and there are now a number of new reference resources available on the topic.
It was, thus, a high priority for many of the 15 institutions that implemented NCCAM education grants to identify or design resources where learners could find reliable, high-quality information about CAM. A survey of these 15 institutions yielded a list of the most highly recommended resources for students to use. This list is summarized in Table 1.
Assessing the literature
Another key skill needed for lifelong learning is the ability to find and interpret the results of medical research about CAM. Although this skill is clearly important for medicine as a whole, evaluating CAM literature is an especially challenging and useful skill for students to learn.
Given the challenges inherent to CAM research, including difficulties in standardizing herbal extracts and blinding interventions such as acupuncture, students evaluating CAM literature must learn to assess gaps in imperfect evidence and to familiarize themselves with how such gaps might be overcome. Because similar obstacles occur also in other areas of medicine, skills learned in assessing CAM literature are widely applicable.
Practicing medicine with imperfect evidence is an issue that all clinicians must confront and one to which students often have difficulty adjusting. Studying how to analyze CAM literature provides valuable experience in addressing this challenge and can help instill long-lasting attitudes of curiosity and inquisition.
A recurring goal among the 15 institutions that received NCCAM education grants was to build such a model of inquiry into their CAM curricula. With the aim of fostering an open-minded, evidence-based approach to research and patient care, programs worked to design modules in which treatments were neither accepted nor discounted on face value; instead, the treatments were investigated to discover what is known scientifically about their mechanism of action, safety, or efficacy.
The 15 institutions that implemented NCCAM education grants faced similar challenges in selecting CAM content, and they settled on similar guiding principles: teach foundational CAM competencies; choose specific content on the basis of evidence, demographics, and types of conditions treated; and provide students with skills for future learning. Such skills include finding reliable CAM resources for answering questions which arise in the course of clinical practice, and knowing how to best search and evaluate the medical literature regarding CAM therapies.
We believe that our summary is the first attempt to formulate explicit guidelines for how to select quality CAM content. Although other groups have published CAM curricula and core competencies in CAM,8,27–30 this summary focuses on the rationale for deciding what concepts to teach rather than on specific recommendations for curricular content. Although the outlined approach is generally applicable to other areas of medicine, in our opinion there are aspects of CAM that are uniquely addressed by the considerations above.
As the evidence base for CAM continues to grow, better clarifying which CAM treatments are more effective than placebos, it will become clearer which aspects of CAM are most suitable for integration into conventional care. By the same token, the process of continuous reevaluation and assessment of the data according to the above principles will further inform decisions about which CAM therapies should be part of the core curriculum for health sciences students.
This work was partially supported by NIH-NCCAM grant #AT00813-06.
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