Ring, Melinda MD; Brodsky, Marc MD; Dog, Tieraona Low MD; Sierpina, Victor MD; Bailey, Michelle MD; Locke, Amy MD; Kogan, Mikhail MD; Rindfleisch, James A. MPhil, MD; Saper, Robert MD, MPH
The Consortium of Academic Health Centers for Integrative Medicine (CAHCIM) defines integrative medicine as “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.”1 In 1993, Eisenberg and colleagues2 first reported on the widespread, public use of complementary and alternative medicine (CAM) approaches not generally taught in medical school or practiced in U.S. hospitals.3 Since then, health care providers increasingly have embraced these approaches in their practice of medicine.4 The research, teaching, and clinical aspects of integrative medicine have developed to meet the public demand for this new comprehensive, interdisciplinary approach to health care.
The public’s growing interest in integrative medicine has stimulated an increase in research and knowledge on the field. Notably, in 1998, the National Institutes of Health (NIH) established the National Center for Complementary and Alternative Medicine (NCCAM) to explore complementary and alternative healing practices in the context of rigorous science, train CAM researchers, and disseminate authoritative information to the public and professionals. In 2012, the annual budget of NCCAM reached $128 million.5
In addition to NCCAM, other NIH institutes and federal agencies also support the systematic evaluation of the scientific foundations of CAM approaches as well as the safety and efficacy of their application to patient care. For instance, in fiscal year 2010, the National Cancer Institute invested $123 million in CAM investigations, including intramural projects and extramural grants; cooperative agreements and contracts; research grants; training grants; and R25 cancer education grants.6
Likewise, academic institutions have responded to the public demand and to the field’s growing evidence base with a variety of integrative medicine curricula and training initiatives. By 1998, 64% of U.S. medical schools offered some form of CAM or integrative medicine curriculum.7 In 2004, Kligler and colleagues8 published a set of core competencies related to integrative medicine education for medical students. The authors noted a steady rise in integrative medicine-related courses in medical schools accredited by the Liaison Committee on Medical Education (LCME). Annual surveys and reports by the Association of American Colleges confirm the rising inclusion of CAM curriculum.9
For residency training, the Society of Teachers of Family Medicine Group on Integrative Medicine outlined a minimum set of integrative medicine competencies based on the six Accreditation Council for Graduate Medical Education (ACGME) core competencies10—medical knowledge, patient care, professionalism, systems-based practice, practice-based learning and improvement, and interpersonal skills and communication—which address the specific knowledge, skills, and attitudes as well as the appropriate educational experiences required of residents to complete graduate medical education in the United States. In addition, the University of Arizona started the Integrative Medicine in Residency (IMR) program, a 200-hour core curriculum, based on the ACGME competencies, that includes both online and on-site learning activities. Thirty family medicine and two internal medicine residencies in the United States have adopted the IMR curriculum.11 In 2012, the U.S. Department of Health and Human Services Health Resources and Services Administration funded $2.5 million for integrative medicine training in preventive medicine residencies.12 This funding was authorized by the Public Health Service Act and the Patient Protection and Affordable Care Act.12
Over the past two decades, integrative medicine clinical fellowships for postresidency physicians have emerged concurrently with integrative medicine residency programs. The University of Arizona offered the first integrative medicine fellowship in 1996. Since then, over 1,000 medical professionals have completed the program, with graduates practicing in 47 states as well as in 15 countries abroad.13,14 Another development is the integrative family medicine program—six residencies added an additional year of fellowship-level training to the standard three-year family medicine residency curriculum.15 In total, 13 clinical fellowships in integrative medicine now exist in the United States, and they are predominantly being established as part of academic medical centers or teaching affiliate hospitals (see Table 1).
However, the lack of uniform training and credentialing for physicians specializing in integrative medicine has limited the field’s recognition within academic institutions and hospital settings. Since 1996, the American Board of Integrative Holistic Medicine has certified over 1,000 physicians, but this certification process lacks rigorous competencies, and eligible candidates are not required to have completed an integrative medicine fellowship program.16 An effort to create a certification process with greater oversight and more stringent eligibility requirements led, in 2012, to the establishment of the American Board of Integrative Medicine (ABoIM) under the auspices of the American Board of Physician Specialties.17 In 2014, the first exams for ABoIM certification will be held. Eventually, to qualify for ABoIM certification, a physician will have to complete an integrative medicine fellowship. However, until 2016, physicians with the necessary training and relevant experience in integrative medicine will be grandfathered in and will be able to sit for the exam.17
Regardless of the certifying organization, the first step to assuring the quality of integrative medicine physicians’ skills and knowledge is collective agreement on the necessary competencies, followed by the development of a corresponding curriculum. Integrative medicine fellowship training standards would ensure that those who promote themselves as integrative medicine “specialists” have met a broadly agreed-on set of training requirements. At the same time, the competencies need to be flexible enough to allow each program to use institution-specific expertise and resources to optimize training opportunities.
In 2010, the CAHCIM, represented by 56 member academic health care institutions with a shared commitment to advance the principles and practices of integrative medicine, convened a two-year task force to draft integrative medicine fellowship core competencies. In this article, we discuss the competencies and the task force’s process to develop them, as well as associated teaching and assessment methods, faculty development, potential barriers, and future directions.
Integrative Medicine Fellowship Core Competencies
Development of the competencies
The CAHCIM’s integrative medicine fellowship core competencies task force undertook the charge of identifying the essential competencies for graduates of integrative medicine fellowships. These competencies were intended to help establish standards for existing integrative medicine fellowships and to provide guidance for future fellowships. The task force included nine physician members of the CAHCIM, chosen for their expertise as integrative medicine educators and their diversity in specialty training (family medicine, internal medicine, pediatrics, geriatrics, palliative care). All coauthors on this article were members of the task force.
The task force members determined a work plan that included a review of the objectives and curricula of the 13 existing integrative medicine clinical fellowships. From January to March 2011, they created a template of questions regarding the program design, curriculum, financial information, educational methods, and required competencies to learn more about the existing fellowships. They contacted all fellowship directors by telephone and e-mail to gather their responses to the questions and for further discussion. Over the subsequent months (April to September 2011), the group systematically collated existing integrative medicine fellowship competencies. Through regular conference calls, task force members used this information, the existing scientific literature, and their own expertise to draft an initial set of competencies, using the ACGME core competencies as the foundation. From October 2011 to April 2012, task force members and other CAHCIM members revised the competencies iteratively through several in-person meetings, monthly conference calls, and e-mail. Workshops at the 2012 International Research Congress on Integrative Medicine and Health in Portland, Oregon (M.R., M.B., R.S.), and at the 2012 International Congress for Educators in Complementary and Integrative Medicine in Washington, DC (M.R., M.B., T.L., V.S.), provided opportunities for public commentary and discussion on the drafted competencies. From November to December 2012, the task force members also solicited constructive feedback from the directors of the existing integrative medicine fellowships.
About the competencies
With the exception of the medical knowledge and patient care competencies, the other integrative medicine competencies align with the corresponding ACGME competencies, which are to a larger degree shared by all medical specialties and subspecialties, and they required only minor additions or modifications specific to integrative medicine (for the task force’s final report, see Supplemental Digital Appendix 1 at http://links.lww.com/ACADMED/A181).
The task force determined that the expectations of fellows in the areas of medical knowledge and patient care are the most distinctive for integrative medicine trainees relative to other specialties. These competencies (see Appendix 1) describe how integrative medicine fellows, on completion of their training, should be able to incorporate the expanding fund of knowledge in integrative medicine into patient care that is safe, effective, patient-centered, timely, evidence-based, efficient, and equitable.18 Four notable areas from the integrative medicine competencies include:
Patient Care and Med...Image Tools
In the 2011 report “Relieving Pain in America,” the Institute of Medicine emphasized the application of knowledge, skills, and attitudes to improve quality of life in patients with pain conditions.19 Over the past decade, research has supported the efficacy of CAM approaches, including tai chi,20 acupuncture,21 massage,22 and yoga,23 for relieving chronic pain of diverse origins. To relieve suffering in patients with pain, an integrative medicine fellow should be able to develop an individualized treatment approach that includes both pharmacological therapies and integrative methods.
Almost 20% of the U.S. population report the use of poorly regulated dietary supplements and diet-based therapies, often because of information from biased or unscientific sources.3 Thus, a thorough understanding of the evidence for the risks and benefits of nutritional and supplement approaches to health and illness is critical. Fellows should be able to both help patients navigate the conflicting claims and counsel them on the approaches they should consider (e.g., the Mediterranean diet)24,25 and those they should avoid because of a lack of efficacy (e.g., saw palmetto for benign prostatic hypertrophy)26 or safety (e.g., ephedra for weight loss).27
The impact of stress on health is now broadly accepted.28 Examples of mind–body practices with demonstrated effectiveness include mindfulness-based stress reduction for anxiety29 and guided imagery for invasive procedures.30 Integrative medicine fellows should know how to implement mind–body approaches for health promotion and treatment of illness.
Integrative medicine fellows should have in-depth scientific knowledge of the relationships of lifestyle behaviors, such as diet, physical activity, and sleep, with health and chronic diseases, such as diabetes,31 osteoarthritis,32 and depression.33 They also should master the skills needed to motivate patients to successfully change their behaviors to incorporate evidence-based, lifestyle-related, self-care interventions.
Additional integrative medicine competencies include knowledge of the characteristics of commonly used, evidence-based CAM practices, the demographic and epidemiologic patterns of CAM and integrative medicine use, and the relevant legal and ethical issues.
Strategies for Teaching Integrative Medicine in Fellowships
Teaching integrative medicine at the fellowship level may follow multiple formats and must allow for a high degree of flexibility for programs to focus on institution-specific areas of specialization. For example, in our survey of existing integrative medicine fellowships, we learned that curricula used supervised clinical practice, integrative medicine rotations, didactic sessions, assigned readings, Web-based modules, and conferences.
In addition, many included a mentorship component to ensure that fellows learn to effectively incorporate knowledge, skills, and attitudes into safe, evidence-based, interdisciplinary care for optimal patient outcomes. Existing fellowships offered diverse clinical experiences, including inpatient care as well as outpatient consultation and/or primary care practices.
As experiential learning is ideal in some areas,8 fellows may participate in or observe a variety of CAM modalities firsthand. Interdisciplinary networking with CAM practitioners from diverse training backgrounds who are appropriately vetted for proper credentials and safe practices may facilitate the delivery of this sort of experiential learning.
Methods to Assess Competence in Fellows and Graduates
After the introduction of these competencies, essential next steps include developing methods to evaluate fellows’ attainment of the competencies, guidelines for certification in integrative medicine, and continuing medical education (CME) requirements for graduates. Assessment techniques to evaluate a fellow’s attainment of the competencies may include direct observation by faculty; testing for mastery of knowledge; completion of education, research, or other scholarly projects; quality of teaching as assessed by learners; and patient care metrics, such as patient satisfaction and health outcomes. For certification in integrative medicine, fellows who seek training in a specific CAM modality should meet licensing requirements according to state regulatory boards, if applicable.
As with all specialty areas, the evolving knowledge base in integrative medicine necessitates that physicians stay current with new and emerging evidence that affects patient care. The American Board of Medical Specialties Maintenance of Certification provides a helpful framework. The 24 member boards are now implementing maintenance of certification programs that aim to foster physicians’ commitment to lifelong learning and competency in their specialty and/or subspecialty area by requiring the ongoing measurement of the six core competencies adopted by the ABMS and ACGME.34
Approaches to Faculty Development
The success of integrative medicine fellowships will depend in large part on the quality of the leaders and faculty. Thus, program directors need to continually identify a sufficient number of qualified faculty members for both educational and clinical mentorship responsibilities. As these faculty members serve as role models, they ideally should perform competently in their specialty area, hold appropriate institutional appointments, and remain up-to-date on their medical licensure and/or the appropriate qualification in their particular areas of teaching.
Integrative medicine fellowship faculty, like faculty in all ACGME-approved fellowships, should be familiar with the ACGME’s general policies and procedures for graduate medical education.35 Thus, core requirements for integrative medicine educators include effective interdisciplinary communication skills, maintenance of competence in their area of teaching, and adequate time to devote to the educational program. The pool of potential faculty with these attributes will continue to grow as physicians increasingly participate in integrative medicine fellowships and other training opportunities.
The recent ACGME guidelines for faculty teaching in residency and fellowship programs call for program leaders and core faculty to participate annually in leadership or faculty development programs relevant to their roles in the training program.36 By doing so, faculty members may enhance the effectiveness of their skills as educators or other positions they hold in the program. Integrative medicine fellowships should incorporate these guidelines as well as a formal requirement that faculty pursue CME credit to remain current in their emerging fields. Both these requirements will help to improve the quality of teaching by faculty members.
Potential Barriers to Implementing the Competencies
A number of potential barriers may challenge the introduction of these competencies into existing and future integrative medicine fellowships. The current lack of ABMS and ACGME accreditation status for the field means that Medicare funding cannot be used for graduate medical education in integrative medicine, notably faculty members’ salaries and their protected time for teaching. Thus, each institution must establish a unique revenue stream to subsidize the fellowship, which may prove challenging.
Negotiating the contrasting paradigms between some CAM modalities and the biomedical model may provide additional barriers to introducing competencies into integrative medicine fellowships. For example, Qi, the life energy or life force concept central to traditional Chinese medicine, is difficult to explain using existing biomedical research techniques and technologies. Using a “best-evidence” approach in CAM modalities may help to avoid such ideological quagmires while optimizing patient care. In addition, by examining the effects of CAM treatments using quantifiable physiologic measures and standardized tools, the growing body of knowledge in integrative medicine continues to provide common ground between different traditions of medicine.
Next, establishing close working relationships between integrative medicine fellows and CAM practitioners may present unique challenges. One of the medical knowledge competencies states that fellows should have a good understanding of the training, licensing, credentialing, and scope of practice of CAM providers. Fellows should be able to collaborate with appropriately credentialed CAM practitioners as part of the process of establishing effective working relationships and interdisciplinary integrative medicine teams. For example, massage therapists, acupuncturists, and art and music therapists now participate together in hospice programs across the country.37
Finally, we recognize that many mid- to late-career integrative medicine physicians have not participated in a formal fellowship but instead have acquired expertise through years of independent training and practice. As with other emerging medical specialties, the “grandfathering” pathway offered by the ABoIM will allow these physicians to be recognized properly for their proficiency.
For integrative medicine approaches to become widely recognized best practices in medicine, the field needs pragmatic clinical research that assesses patient-centered outcomes. The Patient-Centered Outcomes Research Institute (PCORI), authorized by the Patient Protection and Affordable Care Act, is a newly established, independent, nonprofit health research organization that could play an important role in this process. In May 2012, PCORI established its National Priorities and Research Agenda, which outlined five national priorities for research. One of the priorities was “Improving Healthcare Systems,” which explicitly states the need for comparative effectiveness studies on integrative health practices.38
Given the historic trend toward increased use of CAM modalities in the United States, we predict that patient demand for physicians well versed in this field will continue to grow. Physicians trained in integrative medicine, who have close working relationships with highly trained CAM providers, will be ideally positioned to help guide patients through a variety of decision-making paths involving integrative medicine approaches. Chronic pain, stress-mediated conditions, and other multifactorial symptoms that limit a patient’s ability to function are important patient care domains to which integrative medicine will continue to add value. In addition, the medical literature has raised concerns about the lack of professional guidance on using natural products, including herbs, vitamins, and other dietary supplements.39,40 For example, an estimated 1 in 25 elders are at risk for a harmful natural product–drug interaction.41 Physicians trained in integrative medicine will be able to effectively counsel patients, policy makers, and regulatory authorities about the appropriate use or avoidance of natural products.
Patient-centered care, the focal point of our evolving health care system, includes respect for and knowledge of how medical pluralism, cultural diversity, spiritual beliefs, and interdisciplinary teamwork play a significant role in patients’ health and healing. Many professional medical organizations promote these principles, but in practice they can be difficult to implement. Physicians trained in integrative medicine will be well positioned to assume leadership roles as educators and policy advocates in a health care system committed to providing patient-centered care.
Increasingly, academic health centers are establishing integrative medicine fellowships. However, for integrative medicine to be accepted as other medical specialties are, it must demonstrate an equal commitment to ensuring that graduates of these training programs achieve proficiency across a uniform set of competencies. Integrative medicine physicians then will be in a position to add value to the evolving health care environment and its increasing emphasis on patient-centered care and interdisciplinary teams.
Acknowledgments: The authors acknowledge Marina Kaasovic, Consortium associate in the Consortium of Academic Health Centers for Integrative Medicine, for her technical assistance.
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