- Email: [email protected]
Recommended Integrative Medicine Competencies for Family Medicine Residents
REVIEW ARTICLE
RECOMMENDED INTEGRATIVE MEDICINE COMPETENCIES MEDICINE RESIDENTS
FOR
FAMILY
Amy B. Locke, MD,1# Andrea Gordon, MD,2 Mary P. Guerrera, MD,3 Paula Gardiner, MD,4 and Patricia Lebensohn, MD,5
Background: The use of complementary and alternative medicine (CAM) and Integrative Medicine (IM) has grown steadily over the past decade. Patients seek physician guidance, yet physicians typically have limited knowledge and training. There is some coverage of IM/CAM topics in medical schools and residencies but with little coordination or consistency. Methodology: In 2008, the Society of Teachers of Family Medicine (STFM) group on Integrative Medicine began the process of designing a set of competencies to educate Family Medicine residents in core concepts of IM. The goal was creation of a set of nationally recognized competencies tied to the Accreditation Council for Graduate Medical Education (ACGME) domains. These competencies were to be achievable by diverse programs, including those without significant internal resources. The group compiled existing curricula from programs around the country and distilled these competencies through multiple reviews and discussions. Simultaneously, the Integrative Medicine in Residency program run
INTRODUCTION Integrative Medicine (IM) is a term that describes a way of practice that synthesizes conventional medicine with evidencebased complementary and alternative medicine (CAM) therapies. In addition, IM may be considered a philosophy and a
1 Department of Family Medicine, University of Michigan Medical School, Ann Arbor, MI 2 Tufts University Family Medicine Residency Program, Cambridge Health Alliance, Medford, MA 3 Department of Family Medicine, University of Connecticut School of Medicine, Farmington, CT 4 Department of Family Medicine, Boston University Medical School, Boston, MA 5 Arizona Center for Integrative Medicine, University of Arizona, Phoenix, AZ Previous Presentations: Competencies were discussed at the Annual Spring Conference of the STFM in 4/2009 # Correspondence to: Department of Family Medicine, University of Michigan Hospital and Health Systems, 1801 Briarwood Circle Building #10, Ann Arbor, MI 48109 e-mail: [email protected]
308
& 2013 Elsevier Inc. All rights reserved. ISSN 1550-8307/$36.00
by the University of Arizona underwent a similar process. In 2009, these competencies were combined and further developed at the STFM annual meeting by a group of experts. Results: In 2010, the STFM Board approved 19 measurable competencies, each categorized by ACGME domain, as recommended for Family Medicine residencies. Programs have implemented these competencies in various ways given individual needs and resources. Conclusions: This paper reviews the development of IM competencies for residency education in Family Medicine and presents those endorsed by STFM. By educating physicians in training about IM/CAM via competency-based curricula, we aim to promote comprehensive patient-centered care. Key words: integrative medicine, graduate medical education, ACGME competencies (Explore 2013; 9:308-313 & 2013 Elsevier Inc. All rights reserved.)
way of providing healthcare. The Consortium of Academic Health Centers for Integrative Medicine defines IM as “the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence and makes use of all appropriate therapeutic approaches, healthcare professionals and disciplines to achieve optimal health and healing.”1 This definition embodies the essence of primary care and articulates admirable goals for all graduates of medical education. The field of IM has grown tremendously over recent decades, in terms of research, clinical practice, and education. Its spreading popularity among patients has led to increased need for physicians with appropriate counseling skills and a knowledge base of the efficacy and safety of IM/CAM therapies.2,3 The need for health professionals able to effectively address IM/CAM in clinical practice has raised questions about how to adequately train physicians about IM, which encompasses a wide range of therapies and topics, from dietary supplements and botanicals to acupuncture and manipulative therapies. This paper reports the results of one group’s efforts to develop competencies around teaching IM in Family Medicine residencies and to further develop consistency in medical education.
EXPLORE September/October 2013, Vol. 9, No. 5 http://dx.doi.org/10.1016/j.explore.2013.06.005
While IM’s value of the doctor–patient relationship has been a well-respected dimension of medicine and primary care, the addition of CAM therapies challenged the predominant biomedical paradigm of conventionally trained clinicians.4 There are several reasons that may contribute to this situation. For example, prior to the 1990s, CAM was not typically found in medical and residency training, so most physicians have limited training in these areas and find it challenging to discuss CAM with patients or recommend resources for reliable information. In contrast, patients frequently use CAM. A 2007 National Health Interview Survey (NHIS) study reports that 38% of adults and nearly 12% of children use some form of CAM.5 Emerging clinical studies demonstrate that CAM use in the United States varies by patient demographics and medical conditions. Although often stereotyped as a luxury of the wealthy, studies report broader use: 27–88% of older Americans,6–8 32% of military personnel,9 and many of those with chronic problems such as diabetes,10 cancer,11,12 or arthritis13 use CAM approaches or practitioners. CAM practices are also common among immigrant populations.14–16 The gap between the public’s need for information and physicians’ lack of competently providing it needs to be bridged. In addition, as physicians learn about the potential CAM/IM holds for broadening the scope of health and healing options, they can begin the important shift from a diseased base system of care to one focused on prevention, health, and optimal healing.
THE STATE OF MEDICAL EDUCATION AND INTEGRATIVE THERAPIES There have been growing efforts to teach CAM/IM at the medical school, residency, and fellowship levels, but the content and depth of this education is highly variable, as is its integration into the standard curriculum.17,18 Currently, no specific recommendations exist to guide the training of medical students and residents in IM/CAM from the ACGME19 and LCME,20 although there are related questions on national specialty licensing exams. The Consortium of Academic Health Centers for Integrative Medicine was formed in 1999 in order to promote medical education’s inclusion of CAM topics as one of its core missions. Since 2000, the NIH has sponsored program grants to develop CAM training programs in academic medical centers. Despite these efforts, until now there have been no consistent criteria for CAM/IM training in medical education.
Undergraduate Medical Education While the majority of medical schools now offer training in CAM, these courses rarely provide detailed, practical clinical information.21 Those that do offer CAM information often present it as a separate portion of the curriculum. It is rarely integrated into clinical teaching, resulting in students’ frequent belief that patients seek either conventional or alternative approaches but not both. There is little education about IM outside of specific CAM therapies.
Recommended Integrative Medicine Competencies
Graduate Medical Education Residency education has also been of varied quality and content. A number of groups have worked to develop consistent curricula across residency programs, particularly in Family Medicine education. Ideas of how to best include IM in residency training have evolved over time. Over the last 10 years, several separate academic groups defined CAM/IM competencies for Family Medicine Residencies. These groups came together under the umbrella of the STFM Group on IM to develop a single set of suggested competencies and learning objectives for all Family Medicine residencies. The process described below outlines the development of a competency guideline that prepares residents to discuss IM with their patients, recommend evidence-based therapies, and improve patient-centered care. Additionally, curriculum on self-care, that is core to IM, may prevent burnout, improve long-term physician health, and be a model for preservation of physician well-being, is included.22,23 The focus of this paper is to review the development of competencies for residency education in Family Medicine, which led to a document that has been approved and now recommended by the Society of Teachers of Family Medicine (STFM).
METHODS In 2000, the STFM group on IM published a compilation of goals and objectives recommended for inclusion in the residency education of Family Medicine trainees.24 This document represented a 2-year process to elicit the consensus of the STFM IM group, including a number of experts in the field, on the most important aspects of IM. Unfortunately, these goals and objectives were beyond the scope of most Family Medicine programs at that time. The subsequent development of ACGME competencies also affected the structure of IM curriculum recommendations. In 1999, the ACGME endorsed 6 general competency areas: patient care, interpersonal and communication skills, medical knowledge, professionalism, practice-based learning, and systems-based practice. As of 2002, all residency programs are held accountable for education related to these requirements. Many residency programs are still struggling to define and evaluate core competencies for their trainees. As a burgeoning field, IM is ideally placed to define and elucidate its core competencies, including those that overlap with what is already being taught in residency training. In 2007, the Integrative Medicine in Residency (IMR) program, a 200-h, competency-based online curriculum on IM created at the Arizona Center for Integrative Medicine in collaboration with 8 Family Medicine residencies, initiated the development of residency level IM/CAM competencies.25 They followed the guidelines of the ACGME outcome project26 to design a curriculum based on a needs assessment and to address the core IM competencies for residents to attain. This team included 13 Family Medicine faculty, including 12 MDs and 1 PhD, from 10 different institutions including 6 academic medical centers (Albert Einstein, University of Arizona, University of Texas Medical Branch at Galveston, Boston University, University of Michigan, and
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University of Connecticut) and 4 community-based residency programs with some university affiliation. The team used as their foundation the following publications: (1) a needs assessment of 8 Family Medicine residencies, including program directors, faculty, and residents,27 (2) the STFM group on IM suggested curricular guidelines,24 and (3) the medical school guidelines developed by the Education Working Group of the Consortium of Academic Health Centers for Integrative Medicine.28 The IM competencies are based on the ACGME domains and categorized by knowledge, skills, and attitudes. At least one evaluation tool was identified for each competency. In 2008, the STFM group on IM revisited their goals and objectives for residents and decided to review them further, given the changes in the field in the prior decade. These changes included developments in evidence-based medicine (EBM) for CAM therapies, the changing focus of the Residency Review Committee (RRC) to competencies, and the struggles of programs to include recommended goals and objectives. Throughout 2008 and 2009, the STFM IM group reviewed competencies and goals and objectives documents from programs around the country. These were compiled and distributed widely among members of the group on IM through list-serves and conference calls to provide peer review. Since there was a significant overlap between programs, the STFM group on IM decided to use the complete list of the 27 University of Arizona’s IMR competencies as the backbone of the STFM recommendations given their format, the extensive review, and the inter-institutional collaboration that went into their creation. In April 2009, these competencies were presented at a lecture-discussion open session at the annual STFM conference where they were further refined. The final IM competencies list was developed during a conference session at STFM where approximately 20–30 Family Medicine educators worked in small groups addressing each ACGME domain by small group. After the annual meeting, the competencies were distributed to the members of the larger STFM group on IM and comments were collected and incorporated. All 200plus members of this group had the opportunity to comment. The final list presented in this article has 19 measurable competencies, categorized by ACGME domain, as well as by skills, attitudes, and knowledge (see Table 1). In the summer of 2009, this document was submitted to the STFM Board, and in January 2010, it was approved as a set of recommended competencies for all Family Medicine residents. The competencies were accompanied by a set of supporting skills (see Table 2). The competencies are based on six domains with nineteen unique items. The learning objectives include (1) patientcentered history taking using a bio-psychosocial approach; facilitating health behavior; and carrying out a health screening, disease prevention, and treatment when indicated. (2) Increasing medical knowledge using evidence-based medicine and having knowledge of common complementary medicine therapies. (3) Recognize relationship-centered care, respect and understand patient’s cultural beliefs and practices, and respect for peers, staff, consultants, and other practitioners
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who share in the care of patients. (4) Improve patient care based on self-evaluation and life learning. (5) Reflect on personal bias and belief and understand the importance of self-care practices. (6) Finally, understand different reimbursement systems, national, and state standards related to training, licensing, and credentialing for CAM provider (see Tables 1 and 2) for a detailed description. IMPLEMENTATION There are a number of models throughout the United States for implementation of competencies related to IM into Family Medicine curricula. Integrative Medicine in Residency program The IMR program is a 200-h, competency-based online curriculum in IM that is shared by 23 Family Medicine and 2 internal medicine residencies nationwide. The IMR program adopted the STFM version of the competencies after their release. The IM competencies (Table 1) help to guide the curriculum content, as well as the evaluation structure. Some of the participating residencies require that all residents complete the curriculum and others have tracks or areas of concentration that use the IMR. Onsite activities such as workshops, intensive rotations, and integrative patient conferences also support residents’ learning. Each competency is evaluated with one or two tools that populate an online portfolio where residents and faculty can follow individual progress. IM Education in Other Residency Programs Other programs, such as Boston University, the University of Michigan, and the University of Wisconsin, adopted these competencies and use them to guide their curriculum. They use local resources to provide content. Some have developed web teaching tools to broaden resident exposure. Others use available free web resources that have been used in combination with didactics and experiential components, drawing on faculty and community practitioners. The STFM group on IM has supported these efforts by compiling resources on the Family Medicine Digital Resource Library (www.FMDRL.org), including websites, modules, slide sets, and patient handouts. The group is also in the process of developing free web modules for use by students and residents. The skills in Table 2 were required in many programs but were too specific to include in the competencies. Other types of residency programs may use these and/or others like them to implement curricula. DISCUSSION IM encompasses an approach to care and personal wellness that is desired by many patients and physicians, and is being used by an ever-increasing segment of the population. Much of IM is essentially good patient-centered care, consistent with the PCMH model, emphasizing patient values, relationships, and lifestyle. What makes IM unique is its philosophy and approach to prevention and healing more often than its tools and techniques.
Recommended Integrative Medicine Competencies
Table 1. STFM Group on Integrative Medicine Competencies and Learning Objectives* Patient Care: Compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents are expected to do the following: 1 Demonstrate patient-centered history taking, using a bio-psychosocial approach that includes an accurate nutritional history, spiritual history, and inquiry of conventional and complementary treatments. (S) 2 Facilitate health behavior changes in patients, using techniques such as motivational interviewing or appreciative inquiry. (S) 3 Collaborate with patients in developing and carrying out a health screening and management plan for disease prevention, and treatment using conventional and complementary therapies when indicated. (S) Medical Knowledge: Established and evolving biomedical, clinical, epidemiological, social–behavioral science, application to patient care. Residents are expected to do the following: 4 Understand the evidence base for the relationships between health and disease and the following factors: emotion, stress, nutrition, physical activity, social support, spirituality, sleep, and environment. (K) 5 Evaluate the strengths and limitations of evidence-based medicine (EBM) as it applies to conventional and complementary approaches and its translation into patient care. (K) 6 Demonstrate understanding of common complementary medicine therapies, including their history, theory, proposed mechanisms, safety/efficacy profile, contraindications, prevalence, and patterns of use. (K) Interpersonal and Communication Skills: Effective exchange of information and collaboration with patients, families, and health professionals. Residents are expected to do the following: 7 Recognize the value of relationship-centered care as a tool to facilitate healing. (A,K) 8 Demonstrate respect and understanding for patients' interpretations of health, disease, and illness that are based upon their cultural beliefs and practices. (K,S,A) 9 Demonstrate respect for peers, staff, consultants, and CAM practitioners who share in the care of patients. (S,A) Practice-Based Learning and Improvement: To investigate/evaluate care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and lifelong learning. Residents are expected to do the following: 10 Identify personal learning needs related to conventional and complementary medicine. (K,A) 11 Use EBM resources, including those related to CAM, at the point of care. (S) 12 Identify reputable print and/or online resources on conventional and complementary medicine to support professional learning. (K,S) Professionalism: A commitment to carrying out professional responsibilities and an adherence to ethical principles. Residents are expected to do the following: 13 Demonstrate the ability to reflect on elements of patient encounters, including personal bias and belief, to facilitate understanding of relationship-centered care. (S,A) 14 Understand importance of self-care practices to improve personal health, maintain work–life equilibrium, and serve as a role model for patients, staff, and colleagues. (A,K) Systems-Based Practice: Awareness of, and responsiveness to, larger context and system and ability to call effectively on resources to provide optimal healthcare. Residents are expected to do the following: 15 Understand different reimbursement systems and their impact on patient access to both conventional and complementary interventions. (K) 16 Understand national and state standards related to training, licensing, credentialing, and reimbursement of community CAM practitioners. (K) 17 Collaborate with community CAM practitioners and other healthcare specialists in the care of patients, while understanding legal implications and appropriate documentation issues. (S,K) 18 Identify strategies for facilitating access to Integrative Medicine services for their patients, including low-income populations. (K) 19 Understand the principles of designing a healthcare setting that reflects a healing environment. (K,S) n
Types of goals and objectives noted for each competency noted: attitudes (A), knowledge (K), and skills (S).
We present an updated set of IM competencies that builds upon prior work,24 newly vetted by Family Medicine and IM leaders to better reflect changes that have evolved in the field over recent years. These competencies have been developed to incorporate these values and assist programs to better
Recommended Integrative Medicine Competencies
define learning objectives in these areas. If IM is important to our patients, then we must provide adequate training during residency to assure a baseline of competency for all graduates. By following the ACGME domains, these competencies align with the system that residencies are currently using to evaluate
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Table 2. Skills that Support the Competencies 1 Efficiently elicit a typical day’s food and drink intake from a patient. 2 Identify three patients with spiritual beliefs or practices that affected their healthcare and how you worked with them. 3 Gather relevant information regarding safety, efficacy, and cost of a complementary therapy’s intervention and communicate this information clearly to the patient. 4 Develop a treatment plan with a patient using conventional and complementary therapies in concert for maximum benefit. 5 Give examples of common herbs and supplements and explain available research regarding use, safety, and efficacy, or where to find that information. 6 Identify patients who may benefit from mind–body techniques. 7 Describe at least two relaxation techniques in sufficient detail and demonstrate efficiently in the patient care setting. 8 Teach the principles of sleep hygiene. 9 Prescribe nutrition and lifestyle recommendations based on current research specific to individual patient needs. 10 Describe 3 dietary interventions that have been proven to decrease morbidity or mortality in: a. Diabetes b. Coronary artery disease c. Pregnancy d. Osteoarthritis e. Hypertension 11 Be able to explain what aspects the FDA regulates with respect to herbal products and dietary supplements. 12 Assess one’s own healthcare habits and design an achievable plan for self-care.
Table 3. Resources for Programs Online
Community Faculty development
Consortium of Academic Health Centers for Integrative Medicine Natural Medicines Comprehensive Database Natural Standard STFM group on Integrative Medicine www.fmdrl.org University of Arizona Modules and IMR program University of Wisconsin Integrative Medicine Local Practitioners Local schools of alternative therapies such as acupuncture, massage CME courses are offered widely and include American Board of Holistic Medicine Center for Mind–Body Medicine Universities of Arizona, Michigan, New Mexico, Northwestern among others
residents. They outline the training necessary for physicians to help patients navigate an ever-growing world of options for health and wellness, while attending to residents’ own needs for self-care. The limitations of this process include its focus on only Family Medicine residents and exclusion of physicians outside of this role. By only addressing Family Medicine rather than all primary care disciplines, we may reach a smaller audience and have less influence. However, the suggested competencies are easily modified to encompass similar groups of trainees. We hope that over time other disciplines will adopt similar guidelines. We acknowledge the fact that implementation may be challenging to programs depending upon their faculty’s knowledge base, competing curricular demands, and the lack of formalized evaluation tools. We recommend the use of online resources, faculty development, and the use of community resources to achieve full implementation (Table 3). Many of
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the competencies overlap with other areas of Family Medicine curriculum, so they can be folded into existing curricular pieces rather than adding an entirely new rotation or program. They can also be adopted gradually to allow program development. By teaching IM at the residency level, we will create a workforce of physicians poised to address their own and their patients’ needs in the years to come. Competency-based curricula and effective evaluation tools are essential to achieve this goal.
REFERENCES 1. Consortium of Academic Health Centers for Integrative Medicine. 〈http://www.imconsortium.org/about/home.html〉; Accessed 27.07.11. 2. Wahner-Roedler DL, Vincent A, Elkin PL, Loehrer LL, Cha SS, Bauer BA. Physicians’ attitudes toward complementary and alternative medicine and their knowledge of specific therapies:
Recommended Integrative Medicine Competencies
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a survey at an academic medical center. Evid Based Complement Alternat Med. 2006;3(4):495–501. Furlow ML, Patel DA, Sen A, Liu JR. Physician and patient attitudes towards complementary and alternative medicine in obstetrics and gynecology. BMC Complement Altern Med. 2008;8:35. Donnell RW, Genes N, Poses RM. Should medical schools teach integrative medicine? Posted: 12/06/2007. 〈http://www.medscape. com/viewarticle/565472〉; Accessed 26.07.11. Barnes P, Bloom B, Nahin R. Complementary and alternative medicine use among adults and children: United States, 2007. Natl Health Stat Report. 2008;12:1–23. National Center for Complementary and Alternative Medicine and AARP. Complementary and alternative medicine: what people aged 50 and older discuss with their health care providers. Consumer Survey Report. 2010. 〈http://nccam.nih.gov/news/ camstats/2010/introduction.htm〉; Accessed 26.08.11. Arcury TA, Suerken CK, Grzywacz JG, Bell RA, Lang W, Quandt SA. Complementary and alternative medicine use among older adults: ethnic variation. Ethn Dis. 2006;16(3):723–731. Ness J, Cirillo DJ, Weir DR, Nisly NL, Wallace RB. Use of complementary medicine in older Americans: results from the Health and Retirement Study. Gerontologist. 2005;45(4):516–524. Smith TC, Smith B, Ryan MA. Prospective investigation of complementary and alternative medicine use and subsequent hospitalizations. BMC Complement Altern Med. 2008;8:19. Arcury TA, Bell RA, Snively BM, et al. Complementary and alternative medicine use as health self-management: rural older adults with diabetes. J Gerontol B Psychol Sci Soc Sci. 2006;61(2): S62–S70. Greenlee H, Kwan ML, Ergas IJ, et al. Complementary and alternative therapy use before and after breast cancer diagnosis: the Pathways Study. Breast Cancer Res Treat. 2009;117(3):653–665. Ferrucci LM, McCorkle R, Smith T, Stein KD, Cartmel B. Factors related to the use of dietary supplements by cancer survivors. J Altern Complement Med. 2009;15(6):673–680. Feinglass J, Lee C, Rogers M, Temple LM, Nelson C, Chang RW. Complementary and alternative medicine use for arthritis pain in 2 Chicago community areas. Clin J Pain. 2007;23(9):744–749. Tanaka MJ, Gryzlak BM, Zimmerman MB, Nisly NL, Wallace RB. Patterns of natural herb use by Asian and Pacific Islanders. Ethn Health. 2008;13(2):93–108. Loera JA, Reyes-Ortiz C, Kuo YF. Predictors of complementary and alternative medicine use among older Mexican Americans. Complement Ther Clin Pract. 2007;13(4):224–231.
Recommended Integrative Medicine Competencies
16. Mehta DH, Phillips RS, Davis RB, McCarthy EP. Use of complementary and alternative therapies by Asian Americans. Results from the National Health Interview Survey. J Gen Intern Med. 2007;22(6):762–767. 17. Wetzel MS, Eisenberg DM, Kaptchuk TJ. Courses involving complementary and alternative medicine at US medical schools. J Am Med Assoc. 1998;280(9):784–787. 18. Giordano J, Boatwright D, Stapleton S, Huff L. Blending the boundaries: steps toward an integration of complementary and alternative medicine into mainstream practice. J Altern Complement Med. 2002;8(6):897–906. 19. Accreditation Council for Graduate Medical Education. 〈http:// www.acgme.org〉; Accessed 19.09.11. 20. Liaison Committee on Medical Education. Standards for accreditation of medical education programs leading to the M.D. degree. May 2011. 〈http://www.lcme.org/functions2011may. pdf 〉; Accessed 28.09.11. 21. Wetzel MS, Kaptchuk TJ, Haramati A, Eisenberg DM. Complementary and alternative medical therapies: implications for medical education. Ann Intern Med. 2003;138(3): 191–196. 22. IsHak WW, Lederer S, Mandili C, et al. Burnout during residency training: a literature review. J Grad Med Educ. 2009;1(2): 236–242. 23. Eckleberry-Hunt J, Lick D, Boura J, et al. An exploratory study of resident burnout and wellness. Acad Med. 2009;84(2):269–277. 24. Kligler B, Gordon A, Stuart M, Sierpina V. Suggested curriculum guidelines on complementary and alternative medicine: recommendations of the Society of Teachers of Family Medicine Group on alternative medicine. Fam Med. 2000;32(1):30–33. 25. Lebensohn P, Kligler B, Dodds S, et al. Integrative medicine in residency education: developing competency through online curriculum training. J Grad Med Educ. 2012;76–82. 26. Accreditation Council for Graduate Medical Education. Common program requirements: general competencies. 〈http://www.acgme. org/outcome/comp/GeneralCompetenciesStandards21307.pdf 〉; Accessed 27.05.08. 27. Benn R, Maizes V, Guerrera M, Sierpina V, Cook P, Lebensohn P. Integrative medicine in residency: assessing curricular needs in eight programs. Fam Med. 2009;41(10):708–714. 28. Kligler B, Maizes V, Schachter S, et al. Education Working Group. Consortium of Academic Health Centers for Integrative Medicine. Core competencies in integrative medicine for medical school curricula: a proposal. Acad Med. 2004;9(6):521–531.
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RECOMMENDED INTEGRATIVE MEDICINE COMPETENCIES MEDICINE RESIDENTS
FOR
FAMILY
Amy B. Locke, MD,1# Andrea Gordon, MD,2 Mary P. Guerrera, MD,3 Paula Gardiner, MD,4 and Patricia Lebensohn, MD,5
Background: The use of complementary and alternative medicine (CAM) and Integrative Medicine (IM) has grown steadily over the past decade. Patients seek physician guidance, yet physicians typically have limited knowledge and training. There is some coverage of IM/CAM topics in medical schools and residencies but with little coordination or consistency. Methodology: In 2008, the Society of Teachers of Family Medicine (STFM) group on Integrative Medicine began the process of designing a set of competencies to educate Family Medicine residents in core concepts of IM. The goal was creation of a set of nationally recognized competencies tied to the Accreditation Council for Graduate Medical Education (ACGME) domains. These competencies were to be achievable by diverse programs, including those without significant internal resources. The group compiled existing curricula from programs around the country and distilled these competencies through multiple reviews and discussions. Simultaneously, the Integrative Medicine in Residency program run
INTRODUCTION Integrative Medicine (IM) is a term that describes a way of practice that synthesizes conventional medicine with evidencebased complementary and alternative medicine (CAM) therapies. In addition, IM may be considered a philosophy and a
1 Department of Family Medicine, University of Michigan Medical School, Ann Arbor, MI 2 Tufts University Family Medicine Residency Program, Cambridge Health Alliance, Medford, MA 3 Department of Family Medicine, University of Connecticut School of Medicine, Farmington, CT 4 Department of Family Medicine, Boston University Medical School, Boston, MA 5 Arizona Center for Integrative Medicine, University of Arizona, Phoenix, AZ Previous Presentations: Competencies were discussed at the Annual Spring Conference of the STFM in 4/2009 # Correspondence to: Department of Family Medicine, University of Michigan Hospital and Health Systems, 1801 Briarwood Circle Building #10, Ann Arbor, MI 48109 e-mail: [email protected]
308
& 2013 Elsevier Inc. All rights reserved. ISSN 1550-8307/$36.00
by the University of Arizona underwent a similar process. In 2009, these competencies were combined and further developed at the STFM annual meeting by a group of experts. Results: In 2010, the STFM Board approved 19 measurable competencies, each categorized by ACGME domain, as recommended for Family Medicine residencies. Programs have implemented these competencies in various ways given individual needs and resources. Conclusions: This paper reviews the development of IM competencies for residency education in Family Medicine and presents those endorsed by STFM. By educating physicians in training about IM/CAM via competency-based curricula, we aim to promote comprehensive patient-centered care. Key words: integrative medicine, graduate medical education, ACGME competencies (Explore 2013; 9:308-313 & 2013 Elsevier Inc. All rights reserved.)
way of providing healthcare. The Consortium of Academic Health Centers for Integrative Medicine defines IM as “the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence and makes use of all appropriate therapeutic approaches, healthcare professionals and disciplines to achieve optimal health and healing.”1 This definition embodies the essence of primary care and articulates admirable goals for all graduates of medical education. The field of IM has grown tremendously over recent decades, in terms of research, clinical practice, and education. Its spreading popularity among patients has led to increased need for physicians with appropriate counseling skills and a knowledge base of the efficacy and safety of IM/CAM therapies.2,3 The need for health professionals able to effectively address IM/CAM in clinical practice has raised questions about how to adequately train physicians about IM, which encompasses a wide range of therapies and topics, from dietary supplements and botanicals to acupuncture and manipulative therapies. This paper reports the results of one group’s efforts to develop competencies around teaching IM in Family Medicine residencies and to further develop consistency in medical education.
EXPLORE September/October 2013, Vol. 9, No. 5 http://dx.doi.org/10.1016/j.explore.2013.06.005
While IM’s value of the doctor–patient relationship has been a well-respected dimension of medicine and primary care, the addition of CAM therapies challenged the predominant biomedical paradigm of conventionally trained clinicians.4 There are several reasons that may contribute to this situation. For example, prior to the 1990s, CAM was not typically found in medical and residency training, so most physicians have limited training in these areas and find it challenging to discuss CAM with patients or recommend resources for reliable information. In contrast, patients frequently use CAM. A 2007 National Health Interview Survey (NHIS) study reports that 38% of adults and nearly 12% of children use some form of CAM.5 Emerging clinical studies demonstrate that CAM use in the United States varies by patient demographics and medical conditions. Although often stereotyped as a luxury of the wealthy, studies report broader use: 27–88% of older Americans,6–8 32% of military personnel,9 and many of those with chronic problems such as diabetes,10 cancer,11,12 or arthritis13 use CAM approaches or practitioners. CAM practices are also common among immigrant populations.14–16 The gap between the public’s need for information and physicians’ lack of competently providing it needs to be bridged. In addition, as physicians learn about the potential CAM/IM holds for broadening the scope of health and healing options, they can begin the important shift from a diseased base system of care to one focused on prevention, health, and optimal healing.
THE STATE OF MEDICAL EDUCATION AND INTEGRATIVE THERAPIES There have been growing efforts to teach CAM/IM at the medical school, residency, and fellowship levels, but the content and depth of this education is highly variable, as is its integration into the standard curriculum.17,18 Currently, no specific recommendations exist to guide the training of medical students and residents in IM/CAM from the ACGME19 and LCME,20 although there are related questions on national specialty licensing exams. The Consortium of Academic Health Centers for Integrative Medicine was formed in 1999 in order to promote medical education’s inclusion of CAM topics as one of its core missions. Since 2000, the NIH has sponsored program grants to develop CAM training programs in academic medical centers. Despite these efforts, until now there have been no consistent criteria for CAM/IM training in medical education.
Undergraduate Medical Education While the majority of medical schools now offer training in CAM, these courses rarely provide detailed, practical clinical information.21 Those that do offer CAM information often present it as a separate portion of the curriculum. It is rarely integrated into clinical teaching, resulting in students’ frequent belief that patients seek either conventional or alternative approaches but not both. There is little education about IM outside of specific CAM therapies.
Recommended Integrative Medicine Competencies
Graduate Medical Education Residency education has also been of varied quality and content. A number of groups have worked to develop consistent curricula across residency programs, particularly in Family Medicine education. Ideas of how to best include IM in residency training have evolved over time. Over the last 10 years, several separate academic groups defined CAM/IM competencies for Family Medicine Residencies. These groups came together under the umbrella of the STFM Group on IM to develop a single set of suggested competencies and learning objectives for all Family Medicine residencies. The process described below outlines the development of a competency guideline that prepares residents to discuss IM with their patients, recommend evidence-based therapies, and improve patient-centered care. Additionally, curriculum on self-care, that is core to IM, may prevent burnout, improve long-term physician health, and be a model for preservation of physician well-being, is included.22,23 The focus of this paper is to review the development of competencies for residency education in Family Medicine, which led to a document that has been approved and now recommended by the Society of Teachers of Family Medicine (STFM).
METHODS In 2000, the STFM group on IM published a compilation of goals and objectives recommended for inclusion in the residency education of Family Medicine trainees.24 This document represented a 2-year process to elicit the consensus of the STFM IM group, including a number of experts in the field, on the most important aspects of IM. Unfortunately, these goals and objectives were beyond the scope of most Family Medicine programs at that time. The subsequent development of ACGME competencies also affected the structure of IM curriculum recommendations. In 1999, the ACGME endorsed 6 general competency areas: patient care, interpersonal and communication skills, medical knowledge, professionalism, practice-based learning, and systems-based practice. As of 2002, all residency programs are held accountable for education related to these requirements. Many residency programs are still struggling to define and evaluate core competencies for their trainees. As a burgeoning field, IM is ideally placed to define and elucidate its core competencies, including those that overlap with what is already being taught in residency training. In 2007, the Integrative Medicine in Residency (IMR) program, a 200-h, competency-based online curriculum on IM created at the Arizona Center for Integrative Medicine in collaboration with 8 Family Medicine residencies, initiated the development of residency level IM/CAM competencies.25 They followed the guidelines of the ACGME outcome project26 to design a curriculum based on a needs assessment and to address the core IM competencies for residents to attain. This team included 13 Family Medicine faculty, including 12 MDs and 1 PhD, from 10 different institutions including 6 academic medical centers (Albert Einstein, University of Arizona, University of Texas Medical Branch at Galveston, Boston University, University of Michigan, and
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University of Connecticut) and 4 community-based residency programs with some university affiliation. The team used as their foundation the following publications: (1) a needs assessment of 8 Family Medicine residencies, including program directors, faculty, and residents,27 (2) the STFM group on IM suggested curricular guidelines,24 and (3) the medical school guidelines developed by the Education Working Group of the Consortium of Academic Health Centers for Integrative Medicine.28 The IM competencies are based on the ACGME domains and categorized by knowledge, skills, and attitudes. At least one evaluation tool was identified for each competency. In 2008, the STFM group on IM revisited their goals and objectives for residents and decided to review them further, given the changes in the field in the prior decade. These changes included developments in evidence-based medicine (EBM) for CAM therapies, the changing focus of the Residency Review Committee (RRC) to competencies, and the struggles of programs to include recommended goals and objectives. Throughout 2008 and 2009, the STFM IM group reviewed competencies and goals and objectives documents from programs around the country. These were compiled and distributed widely among members of the group on IM through list-serves and conference calls to provide peer review. Since there was a significant overlap between programs, the STFM group on IM decided to use the complete list of the 27 University of Arizona’s IMR competencies as the backbone of the STFM recommendations given their format, the extensive review, and the inter-institutional collaboration that went into their creation. In April 2009, these competencies were presented at a lecture-discussion open session at the annual STFM conference where they were further refined. The final IM competencies list was developed during a conference session at STFM where approximately 20–30 Family Medicine educators worked in small groups addressing each ACGME domain by small group. After the annual meeting, the competencies were distributed to the members of the larger STFM group on IM and comments were collected and incorporated. All 200plus members of this group had the opportunity to comment. The final list presented in this article has 19 measurable competencies, categorized by ACGME domain, as well as by skills, attitudes, and knowledge (see Table 1). In the summer of 2009, this document was submitted to the STFM Board, and in January 2010, it was approved as a set of recommended competencies for all Family Medicine residents. The competencies were accompanied by a set of supporting skills (see Table 2). The competencies are based on six domains with nineteen unique items. The learning objectives include (1) patientcentered history taking using a bio-psychosocial approach; facilitating health behavior; and carrying out a health screening, disease prevention, and treatment when indicated. (2) Increasing medical knowledge using evidence-based medicine and having knowledge of common complementary medicine therapies. (3) Recognize relationship-centered care, respect and understand patient’s cultural beliefs and practices, and respect for peers, staff, consultants, and other practitioners
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who share in the care of patients. (4) Improve patient care based on self-evaluation and life learning. (5) Reflect on personal bias and belief and understand the importance of self-care practices. (6) Finally, understand different reimbursement systems, national, and state standards related to training, licensing, and credentialing for CAM provider (see Tables 1 and 2) for a detailed description. IMPLEMENTATION There are a number of models throughout the United States for implementation of competencies related to IM into Family Medicine curricula. Integrative Medicine in Residency program The IMR program is a 200-h, competency-based online curriculum in IM that is shared by 23 Family Medicine and 2 internal medicine residencies nationwide. The IMR program adopted the STFM version of the competencies after their release. The IM competencies (Table 1) help to guide the curriculum content, as well as the evaluation structure. Some of the participating residencies require that all residents complete the curriculum and others have tracks or areas of concentration that use the IMR. Onsite activities such as workshops, intensive rotations, and integrative patient conferences also support residents’ learning. Each competency is evaluated with one or two tools that populate an online portfolio where residents and faculty can follow individual progress. IM Education in Other Residency Programs Other programs, such as Boston University, the University of Michigan, and the University of Wisconsin, adopted these competencies and use them to guide their curriculum. They use local resources to provide content. Some have developed web teaching tools to broaden resident exposure. Others use available free web resources that have been used in combination with didactics and experiential components, drawing on faculty and community practitioners. The STFM group on IM has supported these efforts by compiling resources on the Family Medicine Digital Resource Library (www.FMDRL.org), including websites, modules, slide sets, and patient handouts. The group is also in the process of developing free web modules for use by students and residents. The skills in Table 2 were required in many programs but were too specific to include in the competencies. Other types of residency programs may use these and/or others like them to implement curricula. DISCUSSION IM encompasses an approach to care and personal wellness that is desired by many patients and physicians, and is being used by an ever-increasing segment of the population. Much of IM is essentially good patient-centered care, consistent with the PCMH model, emphasizing patient values, relationships, and lifestyle. What makes IM unique is its philosophy and approach to prevention and healing more often than its tools and techniques.
Recommended Integrative Medicine Competencies
Table 1. STFM Group on Integrative Medicine Competencies and Learning Objectives* Patient Care: Compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents are expected to do the following: 1 Demonstrate patient-centered history taking, using a bio-psychosocial approach that includes an accurate nutritional history, spiritual history, and inquiry of conventional and complementary treatments. (S) 2 Facilitate health behavior changes in patients, using techniques such as motivational interviewing or appreciative inquiry. (S) 3 Collaborate with patients in developing and carrying out a health screening and management plan for disease prevention, and treatment using conventional and complementary therapies when indicated. (S) Medical Knowledge: Established and evolving biomedical, clinical, epidemiological, social–behavioral science, application to patient care. Residents are expected to do the following: 4 Understand the evidence base for the relationships between health and disease and the following factors: emotion, stress, nutrition, physical activity, social support, spirituality, sleep, and environment. (K) 5 Evaluate the strengths and limitations of evidence-based medicine (EBM) as it applies to conventional and complementary approaches and its translation into patient care. (K) 6 Demonstrate understanding of common complementary medicine therapies, including their history, theory, proposed mechanisms, safety/efficacy profile, contraindications, prevalence, and patterns of use. (K) Interpersonal and Communication Skills: Effective exchange of information and collaboration with patients, families, and health professionals. Residents are expected to do the following: 7 Recognize the value of relationship-centered care as a tool to facilitate healing. (A,K) 8 Demonstrate respect and understanding for patients' interpretations of health, disease, and illness that are based upon their cultural beliefs and practices. (K,S,A) 9 Demonstrate respect for peers, staff, consultants, and CAM practitioners who share in the care of patients. (S,A) Practice-Based Learning and Improvement: To investigate/evaluate care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and lifelong learning. Residents are expected to do the following: 10 Identify personal learning needs related to conventional and complementary medicine. (K,A) 11 Use EBM resources, including those related to CAM, at the point of care. (S) 12 Identify reputable print and/or online resources on conventional and complementary medicine to support professional learning. (K,S) Professionalism: A commitment to carrying out professional responsibilities and an adherence to ethical principles. Residents are expected to do the following: 13 Demonstrate the ability to reflect on elements of patient encounters, including personal bias and belief, to facilitate understanding of relationship-centered care. (S,A) 14 Understand importance of self-care practices to improve personal health, maintain work–life equilibrium, and serve as a role model for patients, staff, and colleagues. (A,K) Systems-Based Practice: Awareness of, and responsiveness to, larger context and system and ability to call effectively on resources to provide optimal healthcare. Residents are expected to do the following: 15 Understand different reimbursement systems and their impact on patient access to both conventional and complementary interventions. (K) 16 Understand national and state standards related to training, licensing, credentialing, and reimbursement of community CAM practitioners. (K) 17 Collaborate with community CAM practitioners and other healthcare specialists in the care of patients, while understanding legal implications and appropriate documentation issues. (S,K) 18 Identify strategies for facilitating access to Integrative Medicine services for their patients, including low-income populations. (K) 19 Understand the principles of designing a healthcare setting that reflects a healing environment. (K,S) n
Types of goals and objectives noted for each competency noted: attitudes (A), knowledge (K), and skills (S).
We present an updated set of IM competencies that builds upon prior work,24 newly vetted by Family Medicine and IM leaders to better reflect changes that have evolved in the field over recent years. These competencies have been developed to incorporate these values and assist programs to better
Recommended Integrative Medicine Competencies
define learning objectives in these areas. If IM is important to our patients, then we must provide adequate training during residency to assure a baseline of competency for all graduates. By following the ACGME domains, these competencies align with the system that residencies are currently using to evaluate
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Table 2. Skills that Support the Competencies 1 Efficiently elicit a typical day’s food and drink intake from a patient. 2 Identify three patients with spiritual beliefs or practices that affected their healthcare and how you worked with them. 3 Gather relevant information regarding safety, efficacy, and cost of a complementary therapy’s intervention and communicate this information clearly to the patient. 4 Develop a treatment plan with a patient using conventional and complementary therapies in concert for maximum benefit. 5 Give examples of common herbs and supplements and explain available research regarding use, safety, and efficacy, or where to find that information. 6 Identify patients who may benefit from mind–body techniques. 7 Describe at least two relaxation techniques in sufficient detail and demonstrate efficiently in the patient care setting. 8 Teach the principles of sleep hygiene. 9 Prescribe nutrition and lifestyle recommendations based on current research specific to individual patient needs. 10 Describe 3 dietary interventions that have been proven to decrease morbidity or mortality in: a. Diabetes b. Coronary artery disease c. Pregnancy d. Osteoarthritis e. Hypertension 11 Be able to explain what aspects the FDA regulates with respect to herbal products and dietary supplements. 12 Assess one’s own healthcare habits and design an achievable plan for self-care.
Table 3. Resources for Programs Online
Community Faculty development
Consortium of Academic Health Centers for Integrative Medicine Natural Medicines Comprehensive Database Natural Standard STFM group on Integrative Medicine www.fmdrl.org University of Arizona Modules and IMR program University of Wisconsin Integrative Medicine Local Practitioners Local schools of alternative therapies such as acupuncture, massage CME courses are offered widely and include American Board of Holistic Medicine Center for Mind–Body Medicine Universities of Arizona, Michigan, New Mexico, Northwestern among others
residents. They outline the training necessary for physicians to help patients navigate an ever-growing world of options for health and wellness, while attending to residents’ own needs for self-care. The limitations of this process include its focus on only Family Medicine residents and exclusion of physicians outside of this role. By only addressing Family Medicine rather than all primary care disciplines, we may reach a smaller audience and have less influence. However, the suggested competencies are easily modified to encompass similar groups of trainees. We hope that over time other disciplines will adopt similar guidelines. We acknowledge the fact that implementation may be challenging to programs depending upon their faculty’s knowledge base, competing curricular demands, and the lack of formalized evaluation tools. We recommend the use of online resources, faculty development, and the use of community resources to achieve full implementation (Table 3). Many of
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the competencies overlap with other areas of Family Medicine curriculum, so they can be folded into existing curricular pieces rather than adding an entirely new rotation or program. They can also be adopted gradually to allow program development. By teaching IM at the residency level, we will create a workforce of physicians poised to address their own and their patients’ needs in the years to come. Competency-based curricula and effective evaluation tools are essential to achieve this goal.
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