For several years, academic leaders and health professionals have called for increased instruction in complementary and alternative medicine (CAM) to familiarize students of health professions schools with the state of the evidence regarding CAM treatment options.1–3 The Society of Teachers of Family Medicine Group on Alternative Medicine suggested curriculum guidelines on CAM,4 and the Education Working Group of the Consortium of Academic Health Centers for Integrative Medicine (CAHCIM) published a proposal for core competencies in integrative medicine for medical school curricula.5 More recently, the Institute of Medicine's panel on CAM use in the United States further demonstrated the rationale for integration with conventional curriculum, suggesting that “health professions schools incorporate sufficient information about CAM … to enable licensed professionals to competently advise their patients about CAM.”6 To support this objective, the National Institutes of Health (NIH) and National Center for Complementary and Alternative Medicine (NCCAM) funded 14 institutions (12 medical schools and two schools of nursing) and the American Medical Student Association (which, in turn, funded an additional six medical schools) through the R25 grant mechanism to develop programs of CAM integration in medical, osteopathic, and nursing education.7 Grants were awarded in cohorts of five per year in 2000, 2001, and 2002–2003. Representatives of all grantees responded to surveys; the responses are the basis of the data cited here. In this article, we focus on the grant recipients' organizational and instructional strategies to integrate CAM into the curriculum, highlighting related faculty development activities.
Strategic Approaches to Integrate CAM into Health Professions Education
Successful integration of CAM into the curriculum requires both personnel and process components. Institutions must determine who will champion the effort at the highest levels, who will lead the program, and what the best methods are for recruiting and training faculty. At the same time, schools must determine how to assess students' interest and support, where CAM content can most easily be integrated into the existing curriculum, and what internal and external partnerships are vital for success.
The overwhelming majority of the CAM programs used a top-down approach to introduce CAM initiatives, with deans acting as either the catalysts or key supporters. Key drivers for garnering broader support included the grant's prestige, as well as concern for keeping pace with peer institutions that were developing expertise in CAM. In allopathic environments where CAM faculty were likely dissociated from other faculty and core programs, these initiatives sought to build collaborative environments to foster CAM content integration. Faculty frequently cited the high prevalence of patient use of CAM, professional obligation to guide patients to reliable information, and good patient care as reasons to integrate CAM into their courses. Another important rationale was the belief that CAM integration would help advance desired educational competencies such as mind–body medicine skills to foster students' self-awareness.
Those heading the institutional CAM education programs were typically doctoral-level strategic leaders (mostly MD, nursing PhD, research PhD, and one DO), most of whom had some formal or informal CAM training or were experienced educators. The fact that these individuals had established credentials helped increase acceptance and inclusion of the CAM thread within the medical or nursing curriculum. Implementation efforts were also greatly facilitated when NCCAM education program directors served as course directors, committee or department chairs, or held decanal responsibilities. In general, these individuals serving on faculty advisory boards or curriculum subcommittees also taught and directed grant activities.
Most institutions used a mix of informal iterative methods to convince key players to engage in the program, such as targeting individuals through one-on-one contact, often starting with critical opinion leaders and faculty with prior relationships to the grantee team. Placing these faculty members on CAM curriculum committees, task forces, or advisory groups helped influence other key faculty. Many institutions also targeted new faculty hires with extensive CAM or integrative medicine interest or training. Simultaneously, grantee teams navigated through any necessary formal channels, such as curriculum committee approvals, and launched faculty development efforts, described in detail below.
Multiple methods were used to drive CAM integration in the curriculum. Several schools seized the opportunity of concurrent curriculum reform or course revisions to integrate CAM. Program leaders first targeted courses felt to have a natural fit for CAM integration, such as patient, physician, society-type courses, or science courses, such as pharmacology. Many schools incorporated at least a partial evidence-based approach to allay negative concerns of faculty, such as by using CAM trials in exercises to build evidence-based analytic skills.
Although integration was the optimal goal, stand-alone or elective courses facilitated curriculum innovation by circumventing some institutional hurdles, testing new material or teaching strategies, and uncovering faculty talents and content interests. Electives were an effective format to assess and build interest before making a course required; successful elective materials subsequently were incorporated into required courses. Electives were sometimes offered as interclerkships—typically one-day to two-week-long, centrally run programs that occur within or between core clerkships to supplement students' clerkship experiences—to introduce “orphan” topics in medical education.8 The University of Massachusetts School of Medicine offered an elective interclerkship on CAM that was subsequently converted to a required interclerkship because of its popularity with students. One by-product of this required interclerkship was that clerkship faculty members were more cognizant of the importance of CAM and were influenced to incorporate more CAM content into their clerkships.
To sustain electives, Louisiana State University faculty noted that it was important to keep the proposed curricular innovation simple and not be dependent on extra financial resources. At the University of California–San Francisco School of Medicine, faculty found that piloting CAM curricula through electives may not be sustainable without outside grant support, and they examined what part of their elective curricula could feasibly be integrated into the required curricula with limited financial support. Some electives were initiated by students, as at Louisiana State University, where the student members of an integrative medicine club started both a health-promotion elective and a self-care elective. In addition to participating in faculty-led programs, students at various schools have taken the lead in running CAM educational initiatives, such as journal clubs and student interest groups. Indeed, most schools were successful in garnering student interest to build bottom-up support for CAM curricula.
Several schools built on existing, successful CAM-related centers or programs (University of California–San Francisco, University of North Carolina, University of Michigan, and University of Minnesota). Other strategies included building relationships with reputable CAM practitioners in the local community, and partnering with faculty in other disciplines (including anthropology, pharmacy, social work, public health, sociology, biology) as well as with instructional designers. All sites included evaluation components, with most sites engaging assistance from a medical education or university-based office. Many saw the use of evaluation metrics as essential for facilitating curriculum committee approval and engaging students in learning new content.
Developing Faculty Capacity to Teach CAM
A key strategy for implementing CAM education involved targeting academic faculty to receive faculty development in CAM. This approach was felt to be most likely to change the learning environment and enhance program sustainability. Faculty development activities focused on increasing awareness, interest, and knowledge, typically through CAM grand rounds, noontime seminars, journal clubs, and continuing education conferences. In addition to lectures, many institutions offered an experiential component. Most institutions focused primarily on educating medical or nursing faculty, whereas others (University of Michigan, University of North Carolina, Oregon Health and Science University, and University of Minnesota) took a broader institutional perspective and involved faculty from multiple professional schools within the larger academic setting.
The majority of programs invited nationally known physician scholars to introduce faculty to safety and efficacy issues pertaining to the use of CAM modalities. However, only a few programs exposed faculty to a cross-disciplinary perspective. For example, in monthly integrative medicine grand rounds, Oregon Health and Science University included local experts for case-focused panel presentations that represented Western medicine, naturopathy, chiropractic and traditional Chinese medicine. This approach facilitated exposure, appreciation, and respect for diverse treatment approaches to patient care. Other institutions designed intensive, comprehensive approaches to deepen faculty learning of CAM.
The educational processes for teaching integrative medicine in these intensive faculty development programs mirrored the values advocated in the clinical practice of integrative health care. The programs used a relationship- and discovery-centered approach to facilitate shifts in attitudes and learning integration. Program teaching faculty included both academic staff and CAM practitioners. The University of Michigan Medical School employed exemplary community-based practitioners and patients who used integrative medicine approaches, and the University of Washington School of Medicine engaged the resources of Bastyr University, an esteemed academic institution with faculty expertise in the practice of naturopathic medicine.
Curriculum content for comprehensive teaching in integrative medicine revolved around six major themes:
- the sociopolitical, historical, and cultural contexts of CAM/integrative medicine;
- the research and clinical evidence pertaining to major modalities within the NCCAM classification system;
- the key methodological issues faced by researchers regarding the efficacy and safety of CAM;
- the identification of self-care wellness strategies (e.g., meditation, imagery, progressive muscle relaxation);
- the recognition of the value of patient-centered care; and
- the exploration of roles, training, and credentialing among CAM providers.
Program faculty wove experiential and didactic evidence-based activities to deepen faculty learning, and they called for faculty trainees to incorporate their learning into educational projects in their respective teaching areas.
Different approaches to comprehensive CAM training evolved across institutions, including both long-term and shorter intensive programs. The interdisciplinary Faculty Scholars Program in integrative health care at the University of Michigan Medical School used a competitive selection process to engage small groups of faculty (8 to 10 participants) in a yearlong program that consisted of monthly full-day sessions. Each program session followed a similar educational integrative template on a specific thematic topic and included didactic evidence-based instruction, patient-based application, experiential learning, discussion of assigned readings, and activity-based homework. Program evaluation indicated major advances in faculty learning, with all participants reporting significant professional and personal growth. The University of Washington School of Nursing's approach to faculty education involved attracting faculty who were interested in integrating CAM content into a high-impact required course to spend a summer month at “CAM camp.” CAM camp has now evolved into the Faculty Integrative Health Program, based on the Michigan model, codirected by faculty from the schools of nursing and medicine, and open to faculty from all health science schools at the University of Washington.
To teach CAM and integrative medicine to students, it is important that academic faculty assimilate knowledge from diverse bodies of literature, experience practices from different traditional systems of care, and appreciate values of relationship-centered practice and partnership. As reported in the educational literature,9–14 such transformative learning can only occur over time, through active engagement in intensive faculty development that is designed to reflect adult learning principles. Critical in this process is the fostering of a safe, supportive learning climate where faculty can openly engage with the curriculum and each other.9,12,13,15–18
CAM Curriculum Integration
Integration into required curricula
All grantee schools had some required coursework related to CAM, ranging from one or two course offerings to more than 20 hours of required curricula at several schools. CAM content was almost exclusively embedded in preexisting course sequences. The nursing schools reported that integration of CAM curricula required little paradigmatic shift at their institutions because issues like wellness, prevention, and holistic health care have long been ingrained in the organizational culture of nursing.
CAM integration extended across the preclinical behavioral and basic sciences, nutrition, health/wellness, and human reproduction courses as well as across clinical experiences. Almost all schools offered some form of an introductory course, generally in the context of preclinical work or within medical third-year clerkships, particularly those in psychiatry and family medicine. Although most of the time dedicated to CAM teaching occurred during the first two years of medical school, some schools, such as the University of California–San Francisco School of Medicine and Maine Medical Center, developed extended learning opportunities for upperclassmen, residents, and/or fellows. At Oregon Health and Science University, all preclinical coursework functioned as part of an interdisciplinary track, demonstrating a unique approach to medical school integration. Nursing programs such as those at Rush University College of Nursing integrated CAM content into undergraduate courses focusing on pharmacotherapeutics, health assessment, care and management of ill patients, and health promotion. At the graduate advanced-practice level, CAM content was integrated into courses such as physical assessment, health promotion, and disease management.
Some schools reported that the lack of a formal review and/or committee approval process restricted progress in curricular integration if decision making was limited to individual course directors. However, most program directors reported teaming with course directors or clerkship directors, and found this one-on-one contact an effective approach to integrating CAM into required curricula. Several program directors enlisted the assistance of specially formed CAM advisory groups to shape curricular planning, course design, and, in some cases, implementation. The American Medical Student Association (AMSA) required that each of its six grantee schools have advisory committees for CAM curriculum development. Involving basic science and clinical clerkship directors in CAM curriculum committee work provided essential assistance at many of the institutions.
CAM-related courses were often taught by the grant program's principal investigators, CAM curriculum committee members, and community CAM providers. Several schools partnered with affiliate organizations to pool faculty resources. For example, Oregon Health and Science University collaborated with faculty working at regional CAM colleges, as did the University of Washington School of Nursing (Seattle), which partnered with faculty from nearby Bastyr University.
CAM course sessions targeted issues related to scientific evidence of efficacy, legal and ethical considerations, and the role of spirituality in health and healing. Attention was also given to recognizing the limitations of science-based approaches and exploring the reasons why CAM is popular with patients as well as with referring physicians and integrative providers. All program directors mentioned providing some form of an evidence-based practice framework to foster a scientifically critical approach to CAM teaching. The developmental level of the learner played a critical role in the selection of appropriate materials. Students' learning was contingent on their ability to understand the material in the context of clinical experience in light of on their overall sophistication in analyzing research evidence. One school, Tufts University School of Medicine, established a firm, evidence-based practice framework before engaging in a formal curriculum-design process. Such a framework encouraged reinforcement of the principle of critically appraising every care modality, whether CAM or conventional, thereby helping to legitimize CAM approaches and to more effectively allay the fears of faculty who were resistant to the idea of including CAM content.
Mind–body medicine and nutrition research fit particularly well with existing course structures at several schools, often in the context of self-care instruction offered through psychiatry, neuroscience, nursing, and preventive health courses. However, some program directors reported difficulty integrating mind–body therapies, and they limited such programming to elective coursework. Topics like herbal medicine were relatively easy to incorporate because of their similarities with traditional health care models and, in the case of herbal medicine, its close relationship with pharmacologic practices. In contrast, homeopathy remained challenging to incorporate, given its greater deviation from conventional health care approaches. Designing curricular content at an appropriate level for medicine upperclassmen was sometimes difficult due to scheduling constraints and the need for students to develop clinical practice skills. Locating qualified preceptors to model best practices was also challenging, and dependent on the availability of integrative health care professionals in the community.
CAM as elective curricula, and other opportunities
Many institutions also included CAM content as elective courses, although integration was the optimal goal. Experiential learning was an important method of delivery for many electives. A desired goal of the faculty was to expose students to both the evidence base and experiential component of CAM therapies in order to gain a full understanding of the efficacy and practice of those therapies. Several medical schools offered rotations to third- or fourth-year students that were immersion experiences with a CAM provider or an integrative medical provider, such as rotations at the University of Minnesota Medical School and the University of Michigan Medical School. The University of California–Irvine College of Medicine was careful to select CAM providers who were credentialed by the university. Schools such as Oregon Health and Science University and the University of North Carolina School of Medicine, having integrative medicine clinics within their medical centers, offered rotations for students on-site so that students could learn both the relationship-centered principles and the practice of integrative medicine. The University of Massachusetts Medical School offered an optional enrichment elective for first- and second-year medical students that combined a didactic presentation on a CAM modality with an experiential and a shadowing opportunity with a community-based CAM practitioner. Faculty at the University of Texas Health Science Center at San Antonio took a cross-cultural approach and taught a popular elective to fourth-year medical students on the traditions of CAM along the United States–Mexico border.
To gain a deeper understanding of the evidence behind CAM, many universities provided research opportunities so that students could acquaint themselves with available library resources while exploring CAM topics in greater depth and learning to critically evaluate data regarding the efficacy and theories behind CAM. A student at the University of Connecticut Health Center explored nutrition to the extent that he taught a nutrition elective that was later integrated into a first- and second-year elective taught by nutrition faculty. Other student projects included the development of a Web-based case and administration of a survey to determine the attitudes and beliefs of basic science faculty about CAM and CAM education.
In addition to didactic and experiential learning and research activities, students also learned about CAM through electives emphasizing self-care and mind–body skills. Most schools used the momentum to increase CAM programs for students, residents, faculty, and patients, particularly in personal wellness and mind–body therapies. A number of sites have used these programs for student and resident recruitment. Georgetown University School of Medicine's mind–body program, which was piloted with 30 students, expanded to 60 to 65 first-year medical students per year, and it has included, to date, more than 500 medical, nursing, and PhD graduate students. The program's success led to its acceptance by the medical school administration as a key component in achieving self-awareness and self-care competency. The University of Connecticut Health Center had an elective in which fourth-year medical students and their significant others (optional) developed personal wellness plans as a way to prepare for the residency experience. The aim was to learn how to maintain personal balance through the next phase of medical training.
Instructional Delivery Strategies for CAM Content
The NCCAM programs integrated CAM into their educational programs by using a variety of instructional delivery strategies, including classroom-based programs, online modules, experiential opportunities, and extracurricular activities. Lectures were the instructional delivery strategy cited as the most “efficient” way to reach large groups of learners, and they were the method used most often to integrate CAM into the educational programs. However, program directors found other approaches, such as experiential learning, to be more effective in achieving program goals.
For example, online learning was used extensively by the University of Minnesota Medical School. Online modules allowed for self-paced learning; were accessible at all hours, all days of the week; could be readily integrated into required courses; or could be used as stand-alone approaches to CAM education. Didactic as well as case-based educational approaches were implemented via online modules. Online learning also offered the advantage of easier revisions of curricular content to maintain currency. A distinct benefit has been the creation of multiple online resources that are available for continued use by students, residents, and faculty.
Many NCCAM-supported education programs found that creating opportunities for learning with direct application to clinical care was valued by students and faculty alike. The University of Texas Medical Branch at Galveston successfully implemented an experiential component into their family medicine clerkship and fourth-year elective that offered didactic instruction on mind–body skills using an evidence-based perspective in conjunction with an experiential component. Participants practiced new skills and were given opportunities for discussion and self-reflection. Other schools offered full programs in mind–body skills training, mindfulness meditation, or The Healer's Art: Awakening the Heart of Medicine, a medical school curriculum designed to help physicians deal with stress and find meaning in their work.19 Students at the University of Connecticut Health Center used AMSA's Healing the Healer module20 to understand wellness and promote personal behavior change.
Other faculty-led educational strategies that were experiential in nature included those involving interaction with CAM practitioners (e.g., classroom-based lecture/demonstrations; field visits). The University of Michigan Medical School paired first-year medical students to observe patient interactions with more than 50 community-based practitioners. After the visits, students reflected on their experiences in small groups that were cofacilitated by academic medicine faculty and CAM providers. The University of California–San Francisco School of Medicine created a first-year medical student elective exchange with the American College of Traditional Chinese Medicine (TCM). They learned the language of TCM and were introduced to what TCM has to offer to health care. Faculty from both schools modeled collaborative care. A number of other schools developed close ties with educational programs from other disciplines. In one case, ongoing interactions between Oregon Health and Science University and CAM colleges within the region led to the development of a formalized educational structure, the Oregon Collaborative in Complementary and Integrative Medicine.
In addition to interacting with faculty from CAM disciplines, some students learned to incorporate CAM into clinical practice by working closely with integrative health care providers within their own disciplines. Faculty at the University of Texas Health Science Center at San Antonio believed that because integrative care was such a novel concept, it was imperative that students have the opportunity to observe someone practicing in this manner. At Tufts University School of Medicine, a collaboration was established with the New England School of Acupuncture that enabled Tufts professional librarians trained in evidence-based medicine to team with both conventional and acupuncture faculty to teach students how to access and evaluate CAM literature.
Evaluation to Inform Continuous Improvement
All educational programs elicited trainee feedback and implemented program changes in an ongoing manner. Some schools reported difficulty in gauging how best to respond to critical trainee input—whether to drop content from the program, bring in new facilitators, or modify the context within which the material was presented. As one measure of impact, many schools used responses to the Association of American Medical Colleges Graduation Questionnaire, which includes questions about teaching CAM content in the medical school curriculum. With the R25 initiative coming to a close for most programs, faculty have been carefully evaluating which content is of greatest value, which delivery strategies are most effective, and which approaches can be self-sustaining. What is most needed is a longitudinal assessment of the impact of teaching CAM on the practice behaviors of clinicians and, ultimately, on the outcomes of patients.
Benefits of CAM Curriculum Integration
Increased faculty capacity
As a result of the faculty development efforts, all grantee institutions except one reported increased capacity in both number and expertise of on-site faculty now available to teach CAM. Schools with more concentrated faculty development efforts had the greatest increase. Enhanced faculty teaching capacity spanned a number of CAM content areas. Close to 40% of the institutions reported faculty available to teach in the five major content areas outlined by NCCAM. Program leaders indicated that faculty expertise was more readily accessible for mind–body therapies and botanical medicine content areas in contrast to manipulative medicine, energy medicine, or whole health care systems. More than 80% of the sites reported in-house faculty available to teach content in these former areas, as well as in skill areas related to CAM history taking, acupuncture, self-care, and research methods.
At several institutions, networking occurred across disciplines to garner internal or external grants that leveraged the work, either in curriculum development or CAM interdisciplinary research. Some grants expanded or solidified existing integrative centers, or they built new programs that now seem sustainable, through methods such as hiring grant staff permanently into departments. Others created new programs such as an integrative medicine fellowship, an acupuncture clinic with an embedded training program, and a CAM certificate program for nurses. Georgetown's School of Medicine created a masters/PhD degree program in CAM. A few schools created new partnerships with CAM programs or schools, including joint programming efforts such as the Tufts University School of Medicine and New England School of Acupuncture Joint Master Degree Program in Pain Management.
A major benefit of the NCCAM CAM Education initiative has been the kind of new and growing collaborations (such as mentioned above) among conventional and CAM providers and trainees from multiple specialties across multiple institutions. Collaborations have resulted in new resources in CAM (particularly Web-based content), research in both CAM and education, integrative centers, and niche programs that include certificates, fellowship training programs, and joint degrees The team approach to patient care has been further broadened to include CAM practitioners, building community- and university-based faculty collaboration, and exploring true integration of clinical interventions.
Collaboration among academic institutions within the NCCAM CAM Education initiative has resulted in additional value, with grantee universities sharing curricula and strategies with each other and other institutions. Program leadership from Georgetown University School of Medicine provided strategies to facilitate many other sites to better incorporate mind–body medicine within the undergraduate curriculum. The University of Michigan Medical School leadership has shared their curriculum with the University of Washington to enable replication of their faculty scholars program, and they are helping a new education grantee funded by NCCAM to develop a similar program at a CAM institution. The University of Washington School of Nursing is partnering with two other R25-supported schools of nursing (Rush University and University of Minnesota) to share strategies for integrating CAM content with nursing faculty across the country by offering workshops at national nursing educational conferences. The six medical schools funded through the AMSA grant shared teaching resources and evaluation strategies and instruments. Lessons learned from this initiative could be applied to other programs seeking to promote multidisciplinary research and education.
Challenges to CAM Curriculum Integration and Delivery
Need for qualified faculty
Challenges to provide appropriate context to CAM content included finding existing academic faculty with sufficient knowledge of CAM and integrative medicine. Faculty development in CAM was seen as essential to foster collaborative curriculum development, facilitate content integration, and expose students to the multiple areas of CAM encountered during patient care. The latter included developing CAM faculty who were comfortable communicating with medical and nursing students using an evidence-based approach. However, faculty development remains a major challenge that is difficult for institutions to meet adequately because of lack of faculty time and resources. Time and resource limitations also constrained attempts at moving some excellent CAM electives into the required curriculum where they would be best suited.
A crowded and changing curriculum
Ongoing changes in curriculum and faculty assignments provided both opportunities to integrate new content and also challenges to maintain those additions. Although one-on-one partnering between key CAM faculty and course directors was the most effective method of actually integrating CAM into the curriculum, problems occurred when a new course director was appointed, resulting in interruption of the partnership and loss of continuity. In response, several schools brought together core teams of faculty to design and teach CAM. This team approach gave more credibility to the curriculum-development process in working with course directors, and it created the necessary long-term stability when individuals changed roles.
Defining best practices
Whereas a number of sites mentioned that they wanted students to work with faculty who model best practices in integrative care as part of their clerkship experiences or other clinical training, we have yet to define clearly what best practices in integrative care are, how to measure them, or how to teach them. Additional work is needed that builds on core competencies proposed by CAHCIM5 and that defines benchmarks from the patient, student, and faculty perspectives. The extent to which integrative means that CAM content is integrated into a curriculum as opposed to inserted into a curriculum has varied across the sites. Further study of the actual positioning of CAM content within those required courses where it is claimed to be integrated may prove instructive. Similarly, a more in-depth analysis of why the CAM area of mind–body proves challenging to integrate at some schools and not others may be useful. It is possible that this inconsistency flows from different understandings of what mind–body medicine entails and whether this topic is being taught from a physiological perspective, or framed within a holistic self-care context.
Sustainability of CAM curricula is important to assess. Most schools have increased capacity to teach integrative medicine, particularly in the areas of mind–body therapies and botanical medicine. In addition to enhanced faculty capacity, the creation of accessible and easily updated Web-based resources of CAM content has been a major contribution that will help sustain curriculum initiatives in the postgrant phase. Partnerships with CAM schools or practitioners that will allow students to participate in experiential learning must be maintained. Partnerships with CAM schools or practitioners that will allow students to participate in experiential learning must be maintained, and follow-up surveys must be considered to help determine what elements, programs, and methods were most sustainable and which aspects of these contribute to good patient care.21–23 Leveraging faculty expertise by expanding interdisciplinary and interprofessional education within and across institutions will be essential, including offering faculty development nationally.
The lessons learned from this relatively large cohort of institutions that employed different strategies for developing faculty competence and for designing, delivering, and sustaining CAM curricula can help inform others interested in incorporating not only CAM, but also other uncharted content areas into required and elective programs. The interdisciplinary nature of both integrative practice and teaching may provide excellent models for teamwork and systems-based approaches at every level of training. Collaborations across participating institutions should continue to generate more tangible products, including joint programs, research, and national presentations to disseminate lessons learned. Finally, we cannot overemphasize the importance of external funding to jumpstart such programs, particularly from a prestigious source such as the NIH, and of institutional commitment to sustain such work into the future.
The authors would like to thank Louise Delagran, MEd, educational specialist, Center for Spirituality and Health, University of Minnesota, and Margaret M. Heitkemper, PhD, RN, FAAN, University of Washington School of Nursing (Seattle). The authors also wish to acknowledge Neal West and Nancy Pearson of the NCCAM Education Program and the respective grantee faculty and staff involved at all the CAM education program institutions.
In addition, the authors wish to acknowledge the NIH NCCAM R25 grants and to thank NIH NCCAM for their support of the R25 grant recipients who were referenced in this article.