Integrative medicine is an approach to the practice of health care based on a sound scientific approach with an emphasis on the responsibility of the physician to engage the patient in his or her own unique plan for health. Essential aspects include the recognition of the importance of the mind—body relationship and a willingness to consider unconventional modalities with informed skepticism and scientific evaluation. Above all, integrative medicine encompasses the caring bond between the patient and the caregiver, and the responsibility of the latter to enable the patient to benefit from a full array of modalities that can be shown to benefit health.
THE ARIZONA PROGRAM
The educational model initially developed by the Program in Integrative Medicine at the University of Arizona College of Medicine provided a significant initial step in defining a medical curriculum grounded in the principles of integrative medicine.1,2,3,4 The further development of this program, described in the preceding article by Maizes et al.5 in this issue of Academic Medicine, moves this process forward, primarily by the continued development of a distance learning model and the creation of “tracks” in the second year of the fellowship. The power of the residential fellowship model, which is the most well-developed and comprehensive aspect described, is that it creates a curriculum de novo for fully trained physicians. This allows us to examine those aspects of medical education that, from the perspective of the Arizona program, are missing or deficient in mainstream medical education. The model is innovative in many aspects; not only does it expand the content of conventional medical education, it markedly expands the process of that education. This process emphasizes several notable aspects as core to the education of the integrative physician: the experience of the physician as patient, the emphasis on the art of clinical integration rather than the mastery of tools, the significance of the physician as a lifelong learner, and the process of self-reflection and physicians' attention to their self-care.
A valuable addition to the University of Arizona program would be an evaluation strategy to identify which aspects of this model should be incorporated in educating all physicians. Furthermore, evaluating what happened when this model was extrapolated to a distance-learning venue would provide valuable information regarding which components work best. A significant aspect and proposed value of the residential fellowship program is the experience of the fellow, based within the on-site community. The authors do not, however, address the challenges faced with attempting to incorporate such an experience in this program. It would be interesting to determine whether there have been significant differences in the educational outcomes between these groups (i.e., those who had on-site experiences and those who did not). It will be essential to evaluate the efficacy of these Arizona models to determine both the range and the limits of their applicability to broader medical education.
INTEGRATIVE MEDICINE AND THE MEDICAL CURRICULUM
It is the goal of the proponents of integrative medicine that the essential aspects of integrative medicine education become embedded within the medical curriculum and included in core competencies in undergraduate and post-graduate medical education. The vision is not to create a subspecialty requiring fellowship training. While this may be outside the scope of the mission of the Arizona program, it is clearly the essential next step facing academic medical education. Without evaluation and delineation of the essential components of this educational model, its utility will be limited.
The authors5 posit that integrative medicine should be taught because patients are dissatisfied and physicians are leaving medicine. We believe that the medical profession must be driven to make changes primarily by the commitment to offer the best possible care, and to prepare our students to provide such care. At present, integrative medicine is largely market-driven and spans the spectrum from evidence-based practices that benefit patients and carry little risk to outright quackery, sometimes with significant risk. Without involvement on the part of our profession, we leave patients uninformed and without medical guidance. We are abdicating our responsibility to both our patients and our students if we do not delve into the domains of what may be termed complementary and alternative practices—not only because patients are at times dissatisfied with conventional approaches, but because of our commitment to their health.
As long as “alternative systems” are thought of as distinct from mainstream therapies, they will be practiced that way. Instead, medical education's goal should be that if practices are effective and benefit patients, then students should be educated in them and all patients should be offered them. This is not to say that practitioners should not understand, to the degree possible, the rationales by which therapies are effective. The treacherous divide that exists now between “alternative” and conventional approaches is that if the former are taught, they are generally taught as add-ons. This well-meant but superficial approach creates the situation where effective therapies from within “alternative” domains may not be offered, while less effective or more dangerous therapies may not be avoided. Such an educational approach perpetuates the separateness of the two medical systems—conventional and alternative.
Only those patients who can afford to pay out-of-pocket have full access to alternative approaches. It is clear that the issues of access to a full range of effective care and the threat of two non-interactive systems of medicine can be addressed through medical education. When medical students and residents are educated in integrative medicine, its therapeutic approaches will be available across socioeconomic divides.
Academic medical education has two possible responses to the need of introducing integrative medicine into the curriculum. One strategy is to create additional independent curricula in the form of electives, study groups, or additional postgraduate education. On first glance this has a certain appeal—it is manageable and doesn't alter the conventional curriculum. Yet if this aspect of medical education is offered electively, then we have introduced it as an approach outside core competencies, and a two-tiered medical system will continue to develop.
The second response, and the real challenge to academic medicine, is to incorporate those philosophies, approaches, and therapies of integrative medicine that form a part of the foundation for the best practice of medicine. This approach necessitates the integration of appropriate aspects of integrative medicine into the existing curriculum. This challenge has not yet been addressed by the Arizona program.
It should be noted that the need for these broad-based curricular changes may call for more creative approaches as well. For example, much of integrative medicine education may be most appropriately introduced as “pre-health” education requirements, i.e., as prerequisites for all health professionals. Much of what was developed in the Arizona model could be taught at the undergraduate level. This would address the difficulty of adding content into an already oversaturated curriculum, and would carry the added benefit of providing a common basis of knowledge, skills, and attitudes across health professions. Those courses within Philosophical Foundations in the Arizona curriculum, such as the Philosophy of Science and Medicine and Culture, would be appropriate for consideration as pre-health requirements.
AN OPPORTUNITY AT DUKE
Our colleagues at Duke University School of Medicine are striving to build upon the work pioneered at the University of Arizona by working toward the integration of appropriate education within the existing curriculum. While we do offer concentrated education in integrative medicine, our effort is focused on working within the existing system to effect the evolution of the entire curriculum. Duke is currently undergoing a full four-year curricular revision, with an emphasis on reintegrating the human aspects of medicine. This clearly creates a unique opportunity, as many of the changes called for in medical education have more to do with the reintegration of the human aspects of healing than with the specifics of alternative systems of medicine.
The aspect of personal reflection and self-care as a part of medical education is also being integrated into our curriculum. Currently there is a required 12-hour self-care course, as well as a retreat for medical students to further explore the practice of self-reflection. This year the self-care curriculum will be introduced during the orientation week for first-year students, and we will offer an intensive retreat experience prior to the start of medical school that will serve to set the values and framework of health for students. This will be based in the concept of mindfulness and self-reflection, and assist medical students in creating their own strategic health plans for their four years of medical school. This experience will teach the philosophy that we cannot learn to optimally help our patients in their health and healing without addressing the same in our own lives.
Maizes et al. reference the Consortium of Academic Health Centers for Integrative Medicine. The work at the University of Arizona described in their paper, as well as work going on at other academic institutions, will be greatly facilitated by this consortium. The initial purpose of the gatherings that founded the consortium, as conceived by Jon Kabat-Zinn, PhD, founder of the stress-reduction clinic at the University of Massachusetts Medical Center in Worcester, was to allow the chancellors (or equivalent) of academic health centers and the leaders of integrative medicine programs to assemble in an informal surrounding with little agenda other than to engage each other and better define the nature of the movement.
The first meeting of what was then called the Academic Consortium on Integrative Medicine was hosted by the Fetzer Institute in Kalamazoo, Michigan, in July 1999. The meeting was attended by representatives from the medical schools at Duke University, Harvard University, Stanford University, the University of Arizona, the University of California—San Francisco, the University of Maryland, the University of Massachusetts, and the University of Minnesota. Perhaps the most significant aspect of this event was the way it was conducted. The highly interactive meeting was facilitated by Jon Kabat-Zinn and was grounded in the principles of mindfulness and self-reflection. This was a new and profound experience for many of the participants, a marked departure from typical academic meetings.
A second meeting was convened in Tucson, Arizona, in September 2000. The original eight institutions were joined by representatives from the medical schools at Albert Einstein/Yeshiva University, Georgetown University, and Thomas Jefferson University. These institutions were selected based on the nature of the integrative medicine initiatives under way at the institutions and the levels of support within their academic administrations. The group decided at that meeting to formally establish a more proactive agenda and to change the name of the group to the Consortium of Academic Health Centers for Integrative Medicine.
At the third meeting, which occurred in January 2002, the consortium was joined by representatives of two additional institutions, Columbia University College of Physicians and Surgeons and the University of Michigan Medical School. Stanford was no longer participating due to a change in leadership. During this meeting, the consortium's mission was defined:
Our mission is to help facilitate the transformation of health care through rigorous scientific studies, new models of clinical care, and innovative educational programs that integrate biomedicine, the complexity of human beings, the intrinsic nature of healing and the rich diversity of therapeutic systems.
A chair and a vice chair were elected, and a steering committee was created with representation from each member institution. Bylaws, membership, and finance subcommittees were formed, and their tasks are now being defined. Working groups of research, clinic, and education were also formed.
The intention of the education working group is to use the collective experience, wisdom, and work in progress at each of the member institutions to formulate curricular goals, focusing first on undergraduate medical education. This work will be critical in addressing many of the issues raised by contemplating the model piloted at Arizona, and will help guide future discussions regarding academic medical education in this domain.
SEEKING THE BEST PRACTICE OF MEDICINE
Regardless of the success of the consortium in developing an improved medical education curriculum that encompasses the goals of integrative medicine, the movement will not succeed unless the health care delivery system enables this form of practice. If we succeed in educating medical students and residents to be more patient-centered in their approach, more embracing of the whole person in their intake and treatment options, and more mindful of their own health and healing, and we do nothing to shift the system within which they will ultimately deliver care, we have done only a disservice to them and to their patients. It is therefore essential that we pilot new health care delivery models in which to teach and practice integrative medicine. At Duke we are developing integrative approaches for the care of chronic conditions and for strategic health planning. To be successful, we will need to demonstrate the benefit of such approaches as well as develop rational means for reimbursement.
As we move forward in moving medical education and practice to incorporate the principles of integrative medicine, we should always be guided by the fact that the content will inevitably and continually change. Nonetheless, the art of medical practice, along with the science, must be taught, modeled, and instilled through undergraduate medical education and through practice. By integration of these values and practices throughout a lifetime of training, integrative approaches will simply become the best practice of medicine.
1. Gaudet TW. Integrative medicine: the evolution of a new approach to medicine and to medical education. Integrative Med. 1998;1(2):67–73.
2. Horigan B, Gaudet TW. The changing of medical education. Alternative Therapies. 2000;6(3):93–100.
3. Gaudet TW, Faass N. Developing an integrative medicine program: the University of Arizona Experience. In: Faass N (ed). Integrating Complementary Medicine into Health Systems. Gaithersburg, MD: Aspen, 2001:35–40.
4. Weil A, Gaudet TW, Faass N. Approaches to continuing medical education. In: Faass N (ed). Integrating Complementary Medicine into Health Systems. Gaithersburg, MD: Aspen, 2001:688–93.
5. Maizes V, Schneider C, Bell I, Weil AT. Integrative medical education: development and implementation of a comprehensive curriculum at the University of Arizona. Acad Med. 2002;77:851–60.