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Incorporation of integrative medicine education into undergraduate medical education: a longitudinal study
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Research Article
Incorporation of integrative medicine education into undergraduate medical education: a longitudinal study Saswati Mahapatra1, Anjali Bhagra1, Bisrat Fekadu2, Zhuo Li3, Brent A. Bauer1, Dietlind L. WahnerRoedler1 1. Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA 2. Mayo Clinic School of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota 55905, USA 3. Biostatistics Unit, Mayo Clinic, Jacksonville, Florida 32224, USA ABSTRACT OBJECTIVE: Integrative medicine (IM) combines complementary medical approaches into conventional medicine and considers the whole person. We implemented a longitudinal IM short-course curriculum into our medical school education. This study aimed to evaluate the feasibility and effectiveness of the curriculum via knowledge and attitude surveys regarding IM among students. METHODS: A mandatory short IM curriculum across all years of medical school was created and taught by IM professionals and physician faculty members with expertise in integrative therapies. Graduating classes of 2015 and 2016 completed the same survey in their first and third years of medical school. Paired data analysis was done, and only students who completed surveys at both time points were included in final analyses. RESULTS: Of 52 students in each class, 17 (33%) in the class of 2015 and 22 (42%) in the class of 2016 completed both surveys. After the IM curriculum, students’ knowledge of and comfort with several IM therapies—biofeedback, mindfulness, and the use of St. John’s wort—improved significantly. Students’ personal health practices also improved, including better sleep, exercise, and stress management for the class of 2015. Students graduating in 2016 reported decreased alcohol use in their third year compared with their first year. CONCLUSION: It is feasible to incorporate IM education into undergraduate medical education, and this is associated with improvement in students’ knowledge of IM and personal health practices. Keywords: course curriculum; education; integrative medicine; medical students Citation: Mahapatra S, Bhagra A, Fekadu B, Li Z, Bauer BA, Wahner-Roedler DL. Incorporation of integrative medicine education into undergraduate medical education: a longitudinal study. J Integr Med. 2017; 15(6): 442–449.
http://dx.doi.org/10.1016/S2095-4964(17)60367-4 Received January 24, 2017; accepted March 29, 2017. Correspondence: Dietlind L. Wahner-Roedler, MD; E-mail: [email protected]
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1 Introduction Integrative medicine (IM) aims to combine conventional and complementary medical approaches in an organized way, with the goal of integrating the best-available evidence toward patients’ well-being, and taking into account the whole person (body, mind, and spirit). [1,2] According to the 2012 National Health Interview Survey report,[3,4] more than one-third of the United States (US) adult population uses some sort of complementary approaches to health. Use of complementary and alternative medicine, more recently referred to as IM, has increased consistently in the US in the past four decades. [5] Reasons for this observed increase include complex medical needs, prevention, wellness promotion, and cultural relevance such as values, beliefs, and philosophical orientations.[6,7] It is estimated that adults in the US spent $14.9 billion out of pocket for visiting IM practitioners and for the purchase of complementary products.[8] Because of the increased use of IM, US medical institutions have acknowledged the need for training in various IM modalities in their curricula. [9] The General Medical Council encourages the integration of complementary medicine teaching into basic medical education.[10] In 2000, the National Center for Complementary and Integrative Health at the National Institutes of Health took the initiative of funding educational projects to incorporate IM into the curricula of conventional health professional schools.[11] It has been determined that physicians need additional evidence-based IM education to provide proper guidance to patients.[12] There is a growing need to educate medical students and physicians in IM and its integration into conventional medicine.[10,13–18] Several studies have assessed the teaching of IM in the framework of new courses. Frye et al.[19] and other studies have reported several ways for medical students to acquire knowledge about IM, such as evidence-based IM courses, [20,21] literature reviews, [22] active learning mechanisms,[23] learner-driven activities,[24] and various other modalities.[25] Studies have investigated the interest and enthusiasm[26,27] of medical students to incorporate IM in their course curriculum.[21,28–30] Most medical students believed that knowledge of IM is important for their future careers.[31,32] In addition, senior medical students were interested in learning and applying IM techniques in practice.[33] Students also believed that patient care could be greatly enhanced if physicians educate themselves about patients’ beliefs and health care behaviors. [34] A study by Rees et al.[35] suggested that further research was needed to explore whether IM education can change the attitudes of medical students. Although some studies have evaluated the knowledge Journal of Integrative Medicine
and attitudes of medical students regarding IM, most of these studies were cross-sectional. In the current study, we implemented a longitudinal method with the introduction of an IM short-course curriculum. The purpose of this study was to evaluate the feasibility and effectiveness of this curriculum by determining knowledge of IM among students entering medical school (in 2011 and 2012) and follow-up of these 2 cohorts in their clinical years (third year). 2 Methods 2.1 Study design The study was conducted by the section of IM and health, which is a part of the general internal medicine division at our institution. The study was approved by our institutional review board. 2.2 Development of an IM course curriculum An IM short-course curriculum, which was mandatory for the medical students, was created and taught by IM professionals and faculty members with doctor of medicine (MD) degree and expertise in integrative therapies. The courses were delivered in lectures, small-group discussions, and student-initiated wellness activities. Course content focused on basic science and experimental and evidence-based knowledge. 2.3 Survey instrument and data collection The survey was designed to address 4 areas of IM: (1) the students’ familiarity and experience with various IM techniques and herbs (23 questions); (2) ratings of the effect of various factors on students’ attitudes toward IM (9 questions); (3) students’ demographics (8 questions); (4) a personal health index (11 questions). Questions regarding IM were derived from a physician survey previously used by the authors in scholarly projects[36,37] and adjusted for medical students. The personal health index was created by us after review of the appropriate literature. An electronic survey instrument was created using the Research Electronic Data Capture (REDCap) tool hosted by our institution. REDCap is a secure, webbased application that is designed to support data capture for research studies.[38] A link to the web-based survey (pretest) was emailed to all first-year medical students entering our institution’s medical school in 2011 and 2012 (classes of 2015 and 2016) during the first month of the school year. One email reminder was sent after 2 weeks to the nonresponders. Answers from completed survey questionnaires were captured in REDCap. Longitudinal posttesting was conducted at the beginning of the students’ third (clinical) year, using the same survey. Data from REDCap were downloaded as Excel files (Microsoft) and imported to SAS software (SAS Institute Inc.) for
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data analysis. The results of the 2 student cohorts were analyzed and compared. 2.4 Data analysis Descriptive statistics for categorical variables were reported as frequency and percentage; continuous variables were reported as mean (standard deviation). When comparing survey answers between the classes of 2015 and 2016, the Chi-square test or Fisher exact test was used for categorical variables, and the two-sample t test or Wilcoxon rank sum test was used for continuous variables. When comparing survey answers between the first and third years for each class, only students who returned surveys at both time points were included. Paired data analysis was used. Survey answers with 2 levels were compared between time points using the McNamara agreement test, and answers with more than 2 levels were treated as ordinal variables and tested with the signed rank test. All statistical tests were two-sided, with the α level set at 0.05 for statistical significance. Analyses were performed using SAS software version 9.4 (SAS Institute Inc, Cary, NC, USA). 3 Results 3.1 Demographics Of the 104 students entering medical school, 52 in both 2011 and 2012, 53 (51%) participated in the electronic survey (24 in 2011 and 29 in 2012). Of the initial
responding cohort, 17 (71%) of the 2011 group (class of 2015) and 22 (76%) of the 2012 group (class of 2016) completed the same survey in their third year (Figure 1). Details of the course curriculum, introduced in the first year of medical school, are summarized in Table 1. The demographics of the participating students at the time of medical school entrance (year 1) and during their third year are summarized in Table 2. Attendance of the IM lecture/workshop increased significantly in year 3 for both classes (P = 0.002 for 2015 and P < 0.001 for 2016). 3.2 Familiarity and experience with various IM modalities Students’ familiarity and experience with 7 IM modalities during year 1 to year 3 of medical school of the 2 cohorts are summarized in Supplemental Table 1 (available from the corresponding author). The only statistically significant difference between the 2 cohorts at year 1 was that more students in the 2016 class indicated that they had personally used biofeedback (P = 0.03). The class of 2016 indicated significantly better familiarity with acupuncture during the third year compared with the class of 2015 (P = 0.01), but familiarity with the other 6 modalities did not differ. As would be expected after having attended lectures and completed coursework, familiarity with various modalities improved significantly at year 3 in the 2 groups: biofeedback and mindfulness for both classes (P = 0.002 for 2015 and P < 0.001 for 2016), in addition to acupuncture, ayurveda, and homeopathy for the class of 2016 (P < 0.05).
52 students entering in 2011
52 students entering in 2012
24 students completed the survey
29 students completed the survey
IM Short-Course Curriculum combining •Didactics incorporating evidence-based knowledge •Interactive and group discussion •Student-initiated wellness activities
17 students (71%) completed the same survey in their 3rd year
22 students (76%) completed the same survey in their 3rd year
Results were analyzed and compared with 1st-year survey results of the same group
Figure 1 Summary of study design IM: integrative medicine.
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3.3 Familiarity with various herbs Familiarity of the students with 7 herbs is summarized in Supplemental Table 2 (available from the corresponding author). In general, students were not very familiar with the herbs at entrance to medical school, and knowledge significantly increased at year 3 only for Echinacea (P < 0.05 for 2015) and St. John’s wort (P < 0.001 for both classes). 3.4 Ratings of effect of various factors on attitudes toward IM Students rated the effect of various factors on their attitudes toward IM (Supplemental Table 3, available from the corresponding author). Most students already indicated at year 1 that results of prospective randomized controlled trials would be most influential toward their belief in the effectiveness of IM. This
percentage increased significantly to 94% and 86% for the 2 classes, respectively, during the third year of school (P < 0.001 for both classes). 3.5 Personal health index Results of the personal health index are summarized in Supplemental Table 4 (available from the corresponding author). The only significant difference between the classes of 2015 and 2016 during the first and third years of medical school was their exercise level at year 1 (class of 2016 more physically active; P = 0.03). The health index improved significantly during medical school for students of both classes: the class of 2015 had improved sleep (P = 0.03), exercise (P = 0.02), and use of stress management techniques (P = 0.002), and the class of 2016 had a significant decrease in alcohol use (P = 0.02).
Table 1 Summary of IM curriculum IM course Mindfulness and stress management techniques
Medical Session student length (h) level Year 1 2
Focus of course contents
Delivery method
Learning outcomes
Assessment strategy
Course faculty
Experimental/ evidence-based
Lecture/ small-group discussion
Familiarity with Improved Academic medical IM modality postsurvey score faculty (MD) with expertise in IM
Dietary supplements
Year 1
1
Basic science/ evidence-based
Lecture/ discussion
Familiarity with Improved Academic medical IM modality postsurvey score faculty (MD) with expertise in IM
Modalities of IM: interest group, nights
Year 1–2
2
Basic science/ hands on/ evidence-based
Lecture/ discussion
Familiarity with Improved Academic medical IM modality postsurvey score faculty (MD, massage therapist, music therapist, animal-assisted therapist, licensed acupuncturist) with expertise in IM
Acupuncture
Year 1
1
Basic science/ evidence-based
Lecture/ discussion
Familiarity with Improved Academic medical IM modality postsurvey score faculty (MD) with IM provider
Summary of IM Year 4
1
Basic science/ evidence-based
Lecture/ discussion
Reinforce Improved Academic medical familiarity with postsurvey score faculty (MD) with IM modality IM provider
Experimental
Lecture/ discussion
Awareness of self-care and personal wellness
Qualitative surveys assessing impact and effectiveness
Activity
Awareness of self-care and personal wellness
Qualitative Student-led surveys assessing activity impact and effectiveness
SLWC initiative: my storya
Years 1–4 1 per month
SLWC initiative: SIWAb
Years 1–4 Varies Experimental (about 20 events/ year)
Student-led activity; students, faculty, and academic support staff
a
A series of noon-hour lunch discussions highlighting human stories of resilience. The speakers speak about a personal or life adversity during their medical careers and how they successfully dealt with it and grew from the experience, followed by discussion. b Supported through the institutional SLWC. IM: integrative medicine; MD: doctor of medicine; SIWA: student-initiated wellness activity; SLWC: Student Life and Wellness Committee.
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www.jcimjournal.com/jim Table 2 Demographics of medical student respondents, classes of 2015 and 2016
Men
2015 (n = 24) 12 (50%)
Year 1 2016 (n = 29) 12 (41%)
Age (years)
24.5 (4.6)
23.5 (3.5)
Item
Year 3 2016 (n = 22) 9 (43%)*
P value
0.53
2015 (n = 17) 7 (41%)
0.38
27.4 (5.2)
25.8 (3.9)
0.30
P value
Race/ethnicity
0.51 3 (13%)
7 (24%)
3 (18%)
Black/African American
1 (4%)
3 (10%)
1 (6%)
3 (14%)
White
18 (75%)
14 (48%)
11 (65%)
11 (50%)
Hispanic
1 (4%)
1 (3%)
0 (0%)
1 (5%)
Indian
1 (4%)
2 (7%)
0 (0%)
1 (5%)
Not reported
2 (7%) 9 (38%)
8 (28%)
Received training in use of IM
1 (4%)
6 (21%)
Intended area of medical practice
2 (12%)
1 (5%)
0.44
17 (100%)
19 (86%)
0.08
4 (24%)
6 (27%)
0.16
0.92
0.11
0.002
< 0.001
0.79
0.08
0.32
0.32
0.32
0.17
4 (17%)
1 (3%)
3 (18%)
0 (0%)
Internal medicine
0 (0%)
4 (14%)
1 (6%)
7 (32%)
Pediatrics
1 (4%)
3 (10%)
2 (12%)
4 (18%)
Nonsurgical subspecialty Surgery (general or other subspecialty) Undecided
2 (8%)
5 (17%)
4 (24%)
5 (23%)
5 (21%)
3 (10%)
3 (18%)
3 (14%)
12 (50%)
13 (45%)
4 (24%)
3 (14%)
10 (42%)
10 (34%)
7 (41%)
8 (36%)
0.59
2016
5 (23%)
Family medicine
Attend church, temple, synagogue
2015
0.81
Asian
Attended IM lecture/workshop
P value Chg
0.76
Values are mean (standard deviation) for continuous variables (age) and number of respondents (%) for categorical variables (the other items). When changes were tested, only students who completed both surveys were included. * : n = 21; Chg: change from year 1 to year 3; IM: integrative medicine.
4 Discussion Because of the increasing popularity of IM in the Western world, many US medical schools have attempted to incorporate IM coursework into their curricula. A recent review of websites for 130 US medical schools found IM didactic courses and clerkships in 66 schools (50.8%).[39] Our institution’s medical school has had an IM curriculum in place for the past 15 years. This curriculum has been rigorously evaluated and modified substantially on the basis of perceived barriers and limitations, as well as feedback from learners and faculty. Several possible methods for the design of IM curricula have been described in the literature.[19–25] It is difficult, however, to determine which is the most effective and most appreciated by students without performing controlled studies. In our study, key challenges to the successful integration of the IM coursework into the overall medical school curriculum included evidence-based teaching,[12] the need to avoid curricular crowding in a busy medical school,[40]
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and students’ involvement.[41,42] A comprehensive evidencebased curriculum was created by experts in our education team. The current curriculum covers all essential principles of IM and is presented across all 4 years of medical school training; this allows for longitudinal delivery of knowledge regarding basic principles and clinical applications of IM. Furthermore, it is different from the system at other institutions because the delivery involves a strong component of student near-peer-led instruction (involvement of more experienced students acting as tutors), along with wellness and personal healthpromotion activities. Near-peer curricular delivery has been shown to be a well-received, effective, and successful model in medical school education. Students appreciate learning from their peers.[43–45] Additionally, in terms of time demands, many of these opportunities are offered as competitive monetary grants, and students at all levels are encouraged to design activities that creatively address mind-body wellness and personal health routines within and outside of regular class schedules and school hours.
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Tracking changes in learners’ attitudes is one strategy to document successful and effective IM instruction.[21] As would be expected, results of our study revealed improvement in knowledge related to these modalities. Our results indicate that students’ knowledge of and comfort with several IM therapies improved significantly: biofeedback (P = 0.002 for 2015; P < 0.001 for 2016), mindfulness (P = 0.002 for 2015; P < 0.001 for 2016), and the use of St. John’s wort (P < 0.001 for both classes). Students’ personal health practices also improved, including improved sleep (P = 0.03), exercise (P = 0.02), and stress management (P = 0.002) for the class of 2015. Students graduating in 2016 reported a decrease in alcohol use compared with their first year (P = 0.02). Students’ knowledge is expected to improve after coursework, but these results are particularly encouraging because the students’ wellness and personal health indices improved. We believe that personal-perceived need, “learning by doing” and peer-led instruction and curricular delivery potentially contributed significantly to these specific findings. Our findings are similar to those of other studies that have reported successful outcomes with mindfulness instruction in medical school.[46–48] The finding that not all parameters investigated showed significant improvement may be explained by the time interval between the 2 surveys and that the survey was a general IM survey, with questions derived from a physician survey previously used by our group in scholarly projects[36,37] and adjusted for medical students. None of the medical school instructors were familiar with the survey. It was gratifying to see that students’ personal health index improved, although this cannot necessarily be attributed to education in and exposure to IM.
7 Conflict of interests The authors declare that there is no conflict of interests regarding the publication of this paper. REFERENCES 1
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5 Strengths and limitations To our knowledge, few longitudinal studies have been conducted with IM curricula in medical schools. We had a unique curriculum, with student- and peer-led initiatives outside of students’ academic schedules. Limitations of this study include that it was conducted in only one medical school with a convenience sample and may not be generalizable to other medical schools. The study design lacks a control group because of the mandatory nature of the IM curriculum in medical school. 6 Conclusion
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The results of this longitudinal study suggest that IM education can be incorporated successfully into undergraduate medical education. Medical schools may consider introducing IM coursework into their curricula to enhance the knowledge and perception of medical Journal of Integrative Medicine
students about IM therapies and ways to combine these approaches in an organized way to advance patient care.
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Research Article
Incorporation of integrative medicine education into undergraduate medical education: a longitudinal study Saswati Mahapatra1, Anjali Bhagra1, Bisrat Fekadu2, Zhuo Li3, Brent A. Bauer1, Dietlind L. WahnerRoedler1 1. Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA 2. Mayo Clinic School of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota 55905, USA 3. Biostatistics Unit, Mayo Clinic, Jacksonville, Florida 32224, USA ABSTRACT OBJECTIVE: Integrative medicine (IM) combines complementary medical approaches into conventional medicine and considers the whole person. We implemented a longitudinal IM short-course curriculum into our medical school education. This study aimed to evaluate the feasibility and effectiveness of the curriculum via knowledge and attitude surveys regarding IM among students. METHODS: A mandatory short IM curriculum across all years of medical school was created and taught by IM professionals and physician faculty members with expertise in integrative therapies. Graduating classes of 2015 and 2016 completed the same survey in their first and third years of medical school. Paired data analysis was done, and only students who completed surveys at both time points were included in final analyses. RESULTS: Of 52 students in each class, 17 (33%) in the class of 2015 and 22 (42%) in the class of 2016 completed both surveys. After the IM curriculum, students’ knowledge of and comfort with several IM therapies—biofeedback, mindfulness, and the use of St. John’s wort—improved significantly. Students’ personal health practices also improved, including better sleep, exercise, and stress management for the class of 2015. Students graduating in 2016 reported decreased alcohol use in their third year compared with their first year. CONCLUSION: It is feasible to incorporate IM education into undergraduate medical education, and this is associated with improvement in students’ knowledge of IM and personal health practices. Keywords: course curriculum; education; integrative medicine; medical students Citation: Mahapatra S, Bhagra A, Fekadu B, Li Z, Bauer BA, Wahner-Roedler DL. Incorporation of integrative medicine education into undergraduate medical education: a longitudinal study. J Integr Med. 2017; 15(6): 442–449.
http://dx.doi.org/10.1016/S2095-4964(17)60367-4 Received January 24, 2017; accepted March 29, 2017. Correspondence: Dietlind L. Wahner-Roedler, MD; E-mail: [email protected]
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1 Introduction Integrative medicine (IM) aims to combine conventional and complementary medical approaches in an organized way, with the goal of integrating the best-available evidence toward patients’ well-being, and taking into account the whole person (body, mind, and spirit). [1,2] According to the 2012 National Health Interview Survey report,[3,4] more than one-third of the United States (US) adult population uses some sort of complementary approaches to health. Use of complementary and alternative medicine, more recently referred to as IM, has increased consistently in the US in the past four decades. [5] Reasons for this observed increase include complex medical needs, prevention, wellness promotion, and cultural relevance such as values, beliefs, and philosophical orientations.[6,7] It is estimated that adults in the US spent $14.9 billion out of pocket for visiting IM practitioners and for the purchase of complementary products.[8] Because of the increased use of IM, US medical institutions have acknowledged the need for training in various IM modalities in their curricula. [9] The General Medical Council encourages the integration of complementary medicine teaching into basic medical education.[10] In 2000, the National Center for Complementary and Integrative Health at the National Institutes of Health took the initiative of funding educational projects to incorporate IM into the curricula of conventional health professional schools.[11] It has been determined that physicians need additional evidence-based IM education to provide proper guidance to patients.[12] There is a growing need to educate medical students and physicians in IM and its integration into conventional medicine.[10,13–18] Several studies have assessed the teaching of IM in the framework of new courses. Frye et al.[19] and other studies have reported several ways for medical students to acquire knowledge about IM, such as evidence-based IM courses, [20,21] literature reviews, [22] active learning mechanisms,[23] learner-driven activities,[24] and various other modalities.[25] Studies have investigated the interest and enthusiasm[26,27] of medical students to incorporate IM in their course curriculum.[21,28–30] Most medical students believed that knowledge of IM is important for their future careers.[31,32] In addition, senior medical students were interested in learning and applying IM techniques in practice.[33] Students also believed that patient care could be greatly enhanced if physicians educate themselves about patients’ beliefs and health care behaviors. [34] A study by Rees et al.[35] suggested that further research was needed to explore whether IM education can change the attitudes of medical students. Although some studies have evaluated the knowledge Journal of Integrative Medicine
and attitudes of medical students regarding IM, most of these studies were cross-sectional. In the current study, we implemented a longitudinal method with the introduction of an IM short-course curriculum. The purpose of this study was to evaluate the feasibility and effectiveness of this curriculum by determining knowledge of IM among students entering medical school (in 2011 and 2012) and follow-up of these 2 cohorts in their clinical years (third year). 2 Methods 2.1 Study design The study was conducted by the section of IM and health, which is a part of the general internal medicine division at our institution. The study was approved by our institutional review board. 2.2 Development of an IM course curriculum An IM short-course curriculum, which was mandatory for the medical students, was created and taught by IM professionals and faculty members with doctor of medicine (MD) degree and expertise in integrative therapies. The courses were delivered in lectures, small-group discussions, and student-initiated wellness activities. Course content focused on basic science and experimental and evidence-based knowledge. 2.3 Survey instrument and data collection The survey was designed to address 4 areas of IM: (1) the students’ familiarity and experience with various IM techniques and herbs (23 questions); (2) ratings of the effect of various factors on students’ attitudes toward IM (9 questions); (3) students’ demographics (8 questions); (4) a personal health index (11 questions). Questions regarding IM were derived from a physician survey previously used by the authors in scholarly projects[36,37] and adjusted for medical students. The personal health index was created by us after review of the appropriate literature. An electronic survey instrument was created using the Research Electronic Data Capture (REDCap) tool hosted by our institution. REDCap is a secure, webbased application that is designed to support data capture for research studies.[38] A link to the web-based survey (pretest) was emailed to all first-year medical students entering our institution’s medical school in 2011 and 2012 (classes of 2015 and 2016) during the first month of the school year. One email reminder was sent after 2 weeks to the nonresponders. Answers from completed survey questionnaires were captured in REDCap. Longitudinal posttesting was conducted at the beginning of the students’ third (clinical) year, using the same survey. Data from REDCap were downloaded as Excel files (Microsoft) and imported to SAS software (SAS Institute Inc.) for
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data analysis. The results of the 2 student cohorts were analyzed and compared. 2.4 Data analysis Descriptive statistics for categorical variables were reported as frequency and percentage; continuous variables were reported as mean (standard deviation). When comparing survey answers between the classes of 2015 and 2016, the Chi-square test or Fisher exact test was used for categorical variables, and the two-sample t test or Wilcoxon rank sum test was used for continuous variables. When comparing survey answers between the first and third years for each class, only students who returned surveys at both time points were included. Paired data analysis was used. Survey answers with 2 levels were compared between time points using the McNamara agreement test, and answers with more than 2 levels were treated as ordinal variables and tested with the signed rank test. All statistical tests were two-sided, with the α level set at 0.05 for statistical significance. Analyses were performed using SAS software version 9.4 (SAS Institute Inc, Cary, NC, USA). 3 Results 3.1 Demographics Of the 104 students entering medical school, 52 in both 2011 and 2012, 53 (51%) participated in the electronic survey (24 in 2011 and 29 in 2012). Of the initial
responding cohort, 17 (71%) of the 2011 group (class of 2015) and 22 (76%) of the 2012 group (class of 2016) completed the same survey in their third year (Figure 1). Details of the course curriculum, introduced in the first year of medical school, are summarized in Table 1. The demographics of the participating students at the time of medical school entrance (year 1) and during their third year are summarized in Table 2. Attendance of the IM lecture/workshop increased significantly in year 3 for both classes (P = 0.002 for 2015 and P < 0.001 for 2016). 3.2 Familiarity and experience with various IM modalities Students’ familiarity and experience with 7 IM modalities during year 1 to year 3 of medical school of the 2 cohorts are summarized in Supplemental Table 1 (available from the corresponding author). The only statistically significant difference between the 2 cohorts at year 1 was that more students in the 2016 class indicated that they had personally used biofeedback (P = 0.03). The class of 2016 indicated significantly better familiarity with acupuncture during the third year compared with the class of 2015 (P = 0.01), but familiarity with the other 6 modalities did not differ. As would be expected after having attended lectures and completed coursework, familiarity with various modalities improved significantly at year 3 in the 2 groups: biofeedback and mindfulness for both classes (P = 0.002 for 2015 and P < 0.001 for 2016), in addition to acupuncture, ayurveda, and homeopathy for the class of 2016 (P < 0.05).
52 students entering in 2011
52 students entering in 2012
24 students completed the survey
29 students completed the survey
IM Short-Course Curriculum combining •Didactics incorporating evidence-based knowledge •Interactive and group discussion •Student-initiated wellness activities
17 students (71%) completed the same survey in their 3rd year
22 students (76%) completed the same survey in their 3rd year
Results were analyzed and compared with 1st-year survey results of the same group
Figure 1 Summary of study design IM: integrative medicine.
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3.3 Familiarity with various herbs Familiarity of the students with 7 herbs is summarized in Supplemental Table 2 (available from the corresponding author). In general, students were not very familiar with the herbs at entrance to medical school, and knowledge significantly increased at year 3 only for Echinacea (P < 0.05 for 2015) and St. John’s wort (P < 0.001 for both classes). 3.4 Ratings of effect of various factors on attitudes toward IM Students rated the effect of various factors on their attitudes toward IM (Supplemental Table 3, available from the corresponding author). Most students already indicated at year 1 that results of prospective randomized controlled trials would be most influential toward their belief in the effectiveness of IM. This
percentage increased significantly to 94% and 86% for the 2 classes, respectively, during the third year of school (P < 0.001 for both classes). 3.5 Personal health index Results of the personal health index are summarized in Supplemental Table 4 (available from the corresponding author). The only significant difference between the classes of 2015 and 2016 during the first and third years of medical school was their exercise level at year 1 (class of 2016 more physically active; P = 0.03). The health index improved significantly during medical school for students of both classes: the class of 2015 had improved sleep (P = 0.03), exercise (P = 0.02), and use of stress management techniques (P = 0.002), and the class of 2016 had a significant decrease in alcohol use (P = 0.02).
Table 1 Summary of IM curriculum IM course Mindfulness and stress management techniques
Medical Session student length (h) level Year 1 2
Focus of course contents
Delivery method
Learning outcomes
Assessment strategy
Course faculty
Experimental/ evidence-based
Lecture/ small-group discussion
Familiarity with Improved Academic medical IM modality postsurvey score faculty (MD) with expertise in IM
Dietary supplements
Year 1
1
Basic science/ evidence-based
Lecture/ discussion
Familiarity with Improved Academic medical IM modality postsurvey score faculty (MD) with expertise in IM
Modalities of IM: interest group, nights
Year 1–2
2
Basic science/ hands on/ evidence-based
Lecture/ discussion
Familiarity with Improved Academic medical IM modality postsurvey score faculty (MD, massage therapist, music therapist, animal-assisted therapist, licensed acupuncturist) with expertise in IM
Acupuncture
Year 1
1
Basic science/ evidence-based
Lecture/ discussion
Familiarity with Improved Academic medical IM modality postsurvey score faculty (MD) with IM provider
Summary of IM Year 4
1
Basic science/ evidence-based
Lecture/ discussion
Reinforce Improved Academic medical familiarity with postsurvey score faculty (MD) with IM modality IM provider
Experimental
Lecture/ discussion
Awareness of self-care and personal wellness
Qualitative surveys assessing impact and effectiveness
Activity
Awareness of self-care and personal wellness
Qualitative Student-led surveys assessing activity impact and effectiveness
SLWC initiative: my storya
Years 1–4 1 per month
SLWC initiative: SIWAb
Years 1–4 Varies Experimental (about 20 events/ year)
Student-led activity; students, faculty, and academic support staff
a
A series of noon-hour lunch discussions highlighting human stories of resilience. The speakers speak about a personal or life adversity during their medical careers and how they successfully dealt with it and grew from the experience, followed by discussion. b Supported through the institutional SLWC. IM: integrative medicine; MD: doctor of medicine; SIWA: student-initiated wellness activity; SLWC: Student Life and Wellness Committee.
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www.jcimjournal.com/jim Table 2 Demographics of medical student respondents, classes of 2015 and 2016
Men
2015 (n = 24) 12 (50%)
Year 1 2016 (n = 29) 12 (41%)
Age (years)
24.5 (4.6)
23.5 (3.5)
Item
Year 3 2016 (n = 22) 9 (43%)*
P value
0.53
2015 (n = 17) 7 (41%)
0.38
27.4 (5.2)
25.8 (3.9)
0.30
P value
Race/ethnicity
0.51 3 (13%)
7 (24%)
3 (18%)
Black/African American
1 (4%)
3 (10%)
1 (6%)
3 (14%)
White
18 (75%)
14 (48%)
11 (65%)
11 (50%)
Hispanic
1 (4%)
1 (3%)
0 (0%)
1 (5%)
Indian
1 (4%)
2 (7%)
0 (0%)
1 (5%)
Not reported
2 (7%) 9 (38%)
8 (28%)
Received training in use of IM
1 (4%)
6 (21%)
Intended area of medical practice
2 (12%)
1 (5%)
0.44
17 (100%)
19 (86%)
0.08
4 (24%)
6 (27%)
0.16
0.92
0.11
0.002
< 0.001
0.79
0.08
0.32
0.32
0.32
0.17
4 (17%)
1 (3%)
3 (18%)
0 (0%)
Internal medicine
0 (0%)
4 (14%)
1 (6%)
7 (32%)
Pediatrics
1 (4%)
3 (10%)
2 (12%)
4 (18%)
Nonsurgical subspecialty Surgery (general or other subspecialty) Undecided
2 (8%)
5 (17%)
4 (24%)
5 (23%)
5 (21%)
3 (10%)
3 (18%)
3 (14%)
12 (50%)
13 (45%)
4 (24%)
3 (14%)
10 (42%)
10 (34%)
7 (41%)
8 (36%)
0.59
2016
5 (23%)
Family medicine
Attend church, temple, synagogue
2015
0.81
Asian
Attended IM lecture/workshop
P value Chg
0.76
Values are mean (standard deviation) for continuous variables (age) and number of respondents (%) for categorical variables (the other items). When changes were tested, only students who completed both surveys were included. * : n = 21; Chg: change from year 1 to year 3; IM: integrative medicine.
4 Discussion Because of the increasing popularity of IM in the Western world, many US medical schools have attempted to incorporate IM coursework into their curricula. A recent review of websites for 130 US medical schools found IM didactic courses and clerkships in 66 schools (50.8%).[39] Our institution’s medical school has had an IM curriculum in place for the past 15 years. This curriculum has been rigorously evaluated and modified substantially on the basis of perceived barriers and limitations, as well as feedback from learners and faculty. Several possible methods for the design of IM curricula have been described in the literature.[19–25] It is difficult, however, to determine which is the most effective and most appreciated by students without performing controlled studies. In our study, key challenges to the successful integration of the IM coursework into the overall medical school curriculum included evidence-based teaching,[12] the need to avoid curricular crowding in a busy medical school,[40]
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and students’ involvement.[41,42] A comprehensive evidencebased curriculum was created by experts in our education team. The current curriculum covers all essential principles of IM and is presented across all 4 years of medical school training; this allows for longitudinal delivery of knowledge regarding basic principles and clinical applications of IM. Furthermore, it is different from the system at other institutions because the delivery involves a strong component of student near-peer-led instruction (involvement of more experienced students acting as tutors), along with wellness and personal healthpromotion activities. Near-peer curricular delivery has been shown to be a well-received, effective, and successful model in medical school education. Students appreciate learning from their peers.[43–45] Additionally, in terms of time demands, many of these opportunities are offered as competitive monetary grants, and students at all levels are encouraged to design activities that creatively address mind-body wellness and personal health routines within and outside of regular class schedules and school hours.
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Tracking changes in learners’ attitudes is one strategy to document successful and effective IM instruction.[21] As would be expected, results of our study revealed improvement in knowledge related to these modalities. Our results indicate that students’ knowledge of and comfort with several IM therapies improved significantly: biofeedback (P = 0.002 for 2015; P < 0.001 for 2016), mindfulness (P = 0.002 for 2015; P < 0.001 for 2016), and the use of St. John’s wort (P < 0.001 for both classes). Students’ personal health practices also improved, including improved sleep (P = 0.03), exercise (P = 0.02), and stress management (P = 0.002) for the class of 2015. Students graduating in 2016 reported a decrease in alcohol use compared with their first year (P = 0.02). Students’ knowledge is expected to improve after coursework, but these results are particularly encouraging because the students’ wellness and personal health indices improved. We believe that personal-perceived need, “learning by doing” and peer-led instruction and curricular delivery potentially contributed significantly to these specific findings. Our findings are similar to those of other studies that have reported successful outcomes with mindfulness instruction in medical school.[46–48] The finding that not all parameters investigated showed significant improvement may be explained by the time interval between the 2 surveys and that the survey was a general IM survey, with questions derived from a physician survey previously used by our group in scholarly projects[36,37] and adjusted for medical students. None of the medical school instructors were familiar with the survey. It was gratifying to see that students’ personal health index improved, although this cannot necessarily be attributed to education in and exposure to IM.
7 Conflict of interests The authors declare that there is no conflict of interests regarding the publication of this paper. REFERENCES 1
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5 Strengths and limitations To our knowledge, few longitudinal studies have been conducted with IM curricula in medical schools. We had a unique curriculum, with student- and peer-led initiatives outside of students’ academic schedules. Limitations of this study include that it was conducted in only one medical school with a convenience sample and may not be generalizable to other medical schools. The study design lacks a control group because of the mandatory nature of the IM curriculum in medical school. 6 Conclusion
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The results of this longitudinal study suggest that IM education can be incorporated successfully into undergraduate medical education. Medical schools may consider introducing IM coursework into their curricula to enhance the knowledge and perception of medical Journal of Integrative Medicine
students about IM therapies and ways to combine these approaches in an organized way to advance patient care.
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