- Email: [email protected]
The Impact of a Mandatory Immersion Curriculum in Integrative Medicine for Graduating Medical Students
BRIEF REPORT
THE IMPACT
MANDATORY IMMERSION CURRICULUM IN INTEGRATIVE MEDICINE FOR GRADUATING MEDICAL STUDENTS OF A
Michelle L. Bailey, MD1 Saumil M. Chudgar, MD, MS2 Deborah L. Engle, EdD, MS3 Sam D. Moon, MD, MPH4 Colleen O'Connor Grochowski, PhD5 and Alison S. Clay, MD6#
Background: Although many Americans utilize complementary and alternative medicine (CAM) services and products, few medical school curricula consistently provide instruction in counseling patients on the use of CAM or strategies for identifying credible evidence on the safety and effectiveness of CAM therapies. Methods: This is a mixed methods study. A sustainable, mandatory, half-day CAM immersion curriculum for graduating medical students is described. Student comfort talking with patients about CAM, their willingness to refer patients to a CAM provider, and adequacy of the CAM curriculum was assessed. Results: Students who participated in this mandatory curriculum, rated the medical school curriculum in CAM as more
INTRODUCTION Use of complementary and alternative medicine (CAM) is prevalent among Americans. According to the 2007 National Health Interview Survey (NHIS) data, almost 40% of the US adult population is using CAM.1 CAM use is also present in pediatric populations with 12% of children having used CAM in the past 12 months.1 While many people are seeking CAM services, patients do not often disclose their use of CAM to physicians, and physicians do not generally ask patients about use or refer them for CAM therapies.2
1 Department of Pediatrics, Duke University School of Medicine, Durham, NC 2 Department of Medicine, Duke University School of Medicine, Durham, NC 3 Duke University School of Medicine, Durham, NC 4 Department of Community and Family Medicine, Duke University, Durham, NC 5 Curricular Affairs, Duke University School of Medicine, Durham, NC 6 Department of Surgery, Duke University School of Medicine, HAFS Building, 2301 Erwin Rd., Durham, NC 27710 # Corresponding Author. e-mail: [email protected]; [email protected]
394
& 2015 Published by Elsevier Inc. ISSN 1550-8307/$36.00
adequate than students at other medical schools without a mandatory curriculum. Students’ narrative comments indicate the curriculum impacts students knowledge about CAM, patient use of CAM, and personal practice with CAM in the future. Conclusions: The timing of the CAM curriculum near to graduation, students’ personal exploration of several CAM modalities through immersion, and student interaction with community CAM providers are aspects of the curriculum that make the curriculum successful and memorable. Key words: Complementary medicine, integrative medicine, alternative medicine, medical education, undergraduate (Explore 2015; 11:394-400 & 2015 Published by Elsevier Inc.)
In 1999, the American Association of Medical Colleges (AAMC) recognized the need for instruction in CAM in undergraduate medical education (UME) and performed a needs assessment.3 Of the 117 US medical schools surveyed about instruction in CAM, 64% offered curricula in CAM, but the majority were not mandatory.3 Overall, 63% of medical students reported that their medical school curriculum in CAM was inadequate on the AAMC's Graduation Questionnaire (GQ) in 1999.4 To address these needs, the National Center for Complementary and Alternative Medicine (NCCAM) awarded 15 R25 education project grants to academic institutions from 2000 to 2008 to develop curricular initiatives in integrative medicine.5 Barriers identified for developing and implementing CAM curricula into UME at the conclusion of these projects included competition for valuable course time, buy-in from faculty and institutional leaders, faculty development, and limited resources.6 Participants in these education projects described six components necessary for successful implementation of a CAM curriculum6,7: 1. Integration into the existing required curriculum, 2. Visibility—making CAM visible as an important component to the educational mission of the academic medical center, 3. Faculty development,
EXPLORE September/October 2015, Vol. 11, No. 5 http://dx.doi.org/10.1016/j.explore.2015.07.003
4. Leadership, 5. Accessible and reliable reference resources, and 6. Long-term sustainability. Studies published about the implementation of CAM curricula since the completion of the R25 education projects generally found the initiatives to be unsustainable or not able to reach a large group of medical students. We describe the successful implementation of a mandatory, half-day immersion in CAM for graduating medical students. This curriculum was not part of, nor was it supported by, an R25 education grant.
METHODS: DEVELOPMENT OF THE CAM CURRICULUM In 2005, a decision was made to add CAM instruction to the fourth year medical school curriculum at Duke University within the Capstone course, a mandatory course held two months prior to medical school graduation. The School of Medicine had recently revised its goals and objectives, and added objectives related to the introduction of CAM to the students. The first year of this curriculum, students attended a 90-min lecture on integrative medicine by faculty and staff at the Duke Center for Integrative Medicine. This event was held in an auditorium. In 2006, the event was moved to the medical center library, a space with greater flexibility and with lower ambient noise. The session was more interactive allowing students the opportunity to try several modalities of CAM. The event was moved to the newly opened Duke Integrative Medicine (Duke IM) Health & Healing Center in 2007, a space architecturally designed to promote contemplation and serenity, including incorporation of natural elements such as arched ceilings, curved walls, natural light, and the sound of cascading water. In 2008, the course was taken over by a new course director, and a new director for medical education at Duke Integrative Medicine, formerly the Duke Integrative Medicine Center, had been appointed. While the experience remained mandatory for all students, students were allowed to pick individual sessions of greatest interest. The timeline for these changes is depicted in Figure 1. The current curriculum consists of a one-hour seminar, “Introduction to Complementary and Integrative Medicine,” followed by an immersion experience. The interactive seminar provides core information (utilization rates of CAM by patients, risks vs. benefits, evidence-based resources, etc.) to begin to build a foundation of integrative medicine knowledge
Location
2005 Auditorium
Attendance
Mandatory
Material
Lecture
Pick modalities
None
and serves to orient students to the interactive fair that occurs later in the course. The Complementary and Integrative Medicine immersion, also called the Duke Integrative Medicine fair (IM Fair), occurs a few days after the didactic session. The fair lasts for four hours, and it is supported by over 30 providers including Duke Faculty, staff, and community CAM providers. Each student has the opportunity to experience four 40-min sessions in the field of integrative medicine such as nutrition, massage, acupuncture, yoga, and biofeedback. In many cases, this is the first time that students have an opportunity to interact directly with community CAM providers. Medical center library staff volunteer their time to serve as shepherds for the event, helping the 100þ students find their way to each of their assigned sessions. IM Fair sessions were originally organized around NCCAM's five CAM domains. As the classification for CAM changed, we recruited practitioners from the categories including: Whole Medical Systems, Integrative Medicine Health Care Models, Manipulative and Body-Based Practices, Mind–Body Medicine, and Self-Care & Lifestyle Practices. Students sign up for one experience within four different rotations; rotations allow for easy movement within the DIM building. The sessions offered each year vary based on availability of providers and ongoing feedback from students and providers. Recent additions include Integrative Approaches to the Patient with Pain and Integrative Oncology. Our last group of offerings is provided in Appendix A. Costs associated with the fair include materials (i.e., $250 for food for the nutrition sessions), a $3000 stipend to partially offset lost revenue at Duke Integrative Medicine (which closes the clinic during the student experience), and an appreciation luncheon for the faculty, staff, and community CAM providers who volunteer their time (total cost $1000). This appreciation luncheon offers “healthy nutrition” provided by an Executive Chef with an understanding of food as medicine and offers community providers an opportunity to network with each other. Faculty support comes from the School of Medicine and is provided as salary to the course director and administrator for the course; the IM Fair represents 10% of the Capstone course. We estimate that it takes roughly 40 h a year to organize, plan, and carry out the fair. Most of this time is dedicated to securing a date to close the center to patient care, recruiting faculty, and determining in which spaces to place those faculty (as different spaces in the building allow for smaller or larger groups of students).
2006 Medical Center Library Mandatory
2007 DIM Center
2008 to present DIM Center
Mandatory
Mandatory
Discussion and Experiential Assigned
Experiential
Experiential
Assigned
Students choose sessions they wanted to attend
Figure 1. Timeline of changes to curriculum.
Mandatory Curriculum in Integrated Medicine
EXPLORE September/October 2015, Vol. 11, No. 5 395
Faculty recruitment is our main concern each year. Durham, NC is a relatively small community with a modest number of providers of integrative medicine. However, our institution received funding from the Bravewell Collaborative from 2004 to 2012, allowing Duke Integrative Medicine to offer faculty development awards to physicians and mid-level providers for a distance-learning fellowship in integrative medicine through the University of Arizona. Many of the volunteer faculty are Bravewell Fellow alumni. Other volunteers work in direct patient care at Duke Integrative Medicine. Volunteers from previous years often offer suggestions for new faculty from within their professional networks. Every year, we retain about 75% of the volunteers. Sustainability is a concern given the need for volunteer faculty. We have held formal conversations with all the volunteers at the appreciation luncheon and informal conversations with individual volunteers before and after the fair (while the volunteers break down their stations). Faculty repeatedly state that they enjoy the opportunity to interact with so many students, to nurture their interest in their CAM fields, and to network with other providers in the local integrative medicine community. To further increase sustainability, we surveyed faculty, staff, and community CAM providers in 2014 to determine interest in participating in the IM fair on a weekend day. More than 75% were willing to continue to volunteer time on the weekend, allowing Duke Integrative Medicine to keep the clinic open for the full weekday, minimizing the loss of revenue.
METHODS: CURRICULUM ASSESSMENT This is a mixed methods study, including quantitative data from the AAMC graduate questionnaire (GQ) as well as qualitative and descriptive data from course evaluations completed by students within 24–48 h of the IM fair. Permission to use Data from the GQ questionnaire was obtained from the AAMC. Review of course evaluation data was submitted to the Duke University Institutional Review Board and considered exempt from further review. All graduating medical students complete the AAMC Graduation Questionnaire (GQ) that includes the question, “Do you believe that the time devoted to your instruction in Complementary and Alternative Medicine was inadequate, appropriate, or excessive?” Since the Capstone course is the last required component of the medical school curriculum and the only required experience in CAM, responses from Duke students were compared to those of other graduating students across the country from 2004 to 2013 using a z-test of proportions to ascertain whether the proportion of Duke students who reported inadequate instruction in CAM was different than national respondents on the GQ.4 Over the years, the course director has utilized several different course evaluations to evaluate the IM fair and the Capstone course. Questions on evaluations were changed when students' responses did not discriminate between lecturers or lecture topics. Pre–post knowledge testing was also removed from the course when student knowledge reliably increased immediately following a session. The one question considered to be most useful by the course director included a single open-ended question, “what will you
396 EXPLORE September/October 2015, Vol. 11, No. 5
Percentage of Graduang Medical Students Reporng Curriculum in IM is "inadequate" 45 40 35 30 25
*
20
*
Duke Naonal Average
15 10
*
*
2008
2009
*
*
*
5 0 2004
2005
2006
2007
2010
2011
2012
Figure 2. Proportion of students reporting CAM curriculum in medical school as inadequate. take away from the CAM experience?” This question was appropriate for students who had vastly different experiences during the IM Fair (yoga vs. nutrition). A qualitative analysis of students' responses on the IM fair evaluation from 2012 and 2013 was conducted to extract themes from this open-ended question. Based on initial qualitative analysis from 2012, the 2013 evaluation was modified to ask students specifically about their comfort talking with patients and CAM providers, their familiarity with principles of evidence-based medicine as it related to CAM, and their willingness to refer patients to CAM (Appendix B). RESULTS Since 2006, when the experiential component was added to the Duke Curriculum, there was a statistically significant difference (np o 0.05) in the number of Duke Students reporting that our medical school's curriculum in integrative medicine was inadequate, compared to the national average. This difference has been sustained since 2006 (Figure 2). More Duke students indicate that their curriculum in integrative medicine was adequate compared to the rest of graduating US medical students. Themes extracted from student comments on the required IM fair evaluation covered a breadth of topics that centered around three major themes: 1) Knowledge about CAM and CAM providers: understanding the breadth of CAM, new knowledge of a specific modality, treating the patient as a “whole” person, the presence or/absence of evidence-based medicine to support the use of CAM, and working with provide “The value of CAM in conditions, particularly pain but also insomnia and functional diseases.” “Integrative Medicine, at its heart, cares for the spiritual, nutritional, emotional and physical person…many parts that traditional medicine omits.” “There is more scientific research on these fields than I realized. Also, some of these treatments are not benign and do carry risks.”
Mandatory Curriculum in Integrated Medicine
2) Patient use of CAM: understanding who uses CAM and why, lack of insurance coverage for CAM “The prevalence of CAM usage was much higher than I thought.” “There are a lot of other options out there for treatment besides traditional medicine and my awareness of those will help better serve my patients who have symptoms refractory to traditional medical treatment.” “I think CAM is a great augment to medical care, but unfortunately, patient access to it is limited by cost and lack of insurance coverage.” 3) Personal practice (as both a patient and a future physician) related to CAM: the need to learn more about CAM, incorporating CAM into practice and/or referring patients to CAM, or using CAM for own self care) “How to present integrative medicine as a team effort— that works in synergy with one another and not against each other. The importance of communication between providers and how each provider could help the patient maximize his or her benefits from another provider.” “Having a personal understanding of some of the modalities of CAM, I will now be less apprehensive in considering CAM in the care of my patients.” “Related to self-care, the greatest take away from this experience is the value of meditation as a clinician. We need to take care of ourselves in order to take care of our patients. Learning how to combine relaxation and alertness requires practice, but it can result in greater focus and rapport in patient interactions.” On the 2013 student evaluation (n ¼ 79), 88.3% of students indicated that the IM fair resulted in new learning, 67.1% indicated that the fair prompted self reflection, 60% indicated that the fair resulted in a desire to learn more about CAM, and 52% said the fair changed their perceptions on CAM. At the conclusion of the fair, very few medical students felt uncomfortable with discussions about CAM (Figure 3).
DISCUSSION Over the past 10 years, we have built and sustained a successful curriculum in complementary and alternative medicine at our medical school. We attribute the success of our program, based Student Comfort with CAM 100% 80% 60% uncomfortable moderate comfort
40%
completely comfortable 20% 0% Talking with Paents
Talking with Praconers
Using EBM to analyze CAM
Figure 3. Student comfort talking with patients about CAM, talking with CAM providers and referring patients to CAM.
Mandatory Curriculum in Integrated Medicine
on students responses to the Graduate Questionnaire, and the students responses to open-ended questions on the IM Fair evaluations, to five aspects of the curriculum: (1) the timing of the program in the fourth year of medical school, (2) the immersive/experiential component of the curriculum, (3) the mandatory nature of our program, (4) the building space, and (5) a modest financial commitment from our institution. This curricular effort has been successful in part due to the timing of the Integrative Medicine fair within the fourth year curriculum. By this point in their training, students have learned the “essentials” of medicine. They are beginning to think about how they will practice medicine in internship and residency. Students seem willing to challenge pre-existing beliefs about medicine and develop personal practices with regard to complementary and integrative medicine. Having completed 3.75 years of medical school, students are aware of how physically and emotionally exhaustive medical training can be. They are interested in strategies for improving and supporting their own self-care throughout their medical career. The immersive nature of this event also contributes to its success. Instead of engaging students in academic argument, students are asked to participate in several modalities (Appendix A) and to consider how these activities might benefit themselves and/or their patients. The experiential nature of the event often informs those who previously were skeptical. The mandatory nature of this event is important. Like many other institutions, we have a CAM elective, but few students participate in this elective each year (limited to a maximum of four students). These students often already have interest in and positive attitudes towards CAM. Making this experience mandatory ensures student exposure to CAM and challenges students with preconceived, negative opinions about CAM. However, allowing students to pick modalities of greatest interest makes the experience more palatable to learners. These changes to the curriculum, adapted in 2008, made a noticeable, albeit not quite statistically significant, change on the GQ questionnaire. We are fortunate to have such a beautiful, committed space in which integrative medicine is practiced daily. The physical location sets the tone for the day; the minute the students enter this space, it is clear that this experience will be different than the high stress, high paced experiences at other times during medical school. While this is not possible for many academic medical centers, simply moving away from the central health system's location to a more quiet space may be adequate; we noticed a change when we moved to the Medical Center Library space in 2006. The sustainability of our curriculum has demanded modest financial support from the School of Medicine, dedicated time within the Duke Integrative Medicine facility, and a volunteer faculty consisting of Duke faculty, staff and community providers in complementary and alternative medicine. The breadth of experiences offered to the students and the providers' extensive experience is essential to the success of the IM Fair. The sheer number of offerings allows students to interact with a number of providers across a variety of CAM modalities and gives students' choice about their participation. Although we are anxious to recruit and retain faculty, we have not found this to be particularly difficult because the providers value the networking time during the appreciation luncheon.
EXPLORE September/October 2015, Vol. 11, No. 5 397
CONCLUSIONS AND FUTURE DIRECTIONS Future efforts for the Integrative Medicine fair will include a greater focus on resilience and adaptation for interprofessional education. The need to focus on resilience was identified through our qualitative analysis of student evaluation comments. Although, students described gaining knowledge about CAM and expressed increased willingness to talk with and refer patients to CAM—all objectives identified by previous CAM educators for students in allopathic medicine programs8,9—students also expressed an interest in utilizing CAM for their own benefit. In addition, there has been increased attention given the need to foster resilience among medical students within the medical community.10 Future IM fairs will promote discussion about use of CAM for self-care. We will also adapt the IM fair to include learners from several professions, including the professional programs for physical therapy, physician assistants and nursing at our institution. Since these professions often include differing emphasis on pain management, patient advocacy, and movement within their explicit curricula, including learners from these schools may improve collaboration and attitudes towards CAM. We hope to study these changes by comparing and contrasting student experiences between professions, including attitudes towards CAM, willingness to refer to CAM, and knowledge about the use of CAM for specific medical conditions (sleep disturbances, headaches, and depression). We will also add new questions about willingness to use CAM for self-care to the evaluations. Finally, our CAM providers have indicated, during formal discussion in the appreciation luncheon and informally before and after the sessions, that they would like to include additional time for networking during the fair. Many indicated interest in the skills of other providers and would like an opportunity to explore modalities other than their own during the fair. This networking would allow providers to refer patients to each other. Since providers already value the networking opportunity, we hope to add time at the start or end of the IM Fair to allow CAM providers to experience each other's practice and to survey providers more formally about their participation in the fair.
Acknowledgments
We would like to extend gratitude to all of the community CAM providers who have volunteered dozens of hours to this project over the years. These volunteers include a commitment of staff from the Duke Medical Center Library who facilitated the fair in 2006 and who remain involved after the sessions moved to Duke Integrative Medicine. The authors would also like to thank Rob Tobin, the course coordinator for the Capstone course for his tireless efforts at making the IM fair a success and Duke Integrative Medicine for their commitment to this project. Finally, we would like to acknowledge Ruth Wolever, PhD, who offered insightful editing and review of this article.
APPENDIX A For course evaluation from 2013, see Table A1.
398 EXPLORE September/October 2015, Vol. 11, No. 5
APPENDIX B. COURSE EVALUATION FROM 2013 Duke Integrative Medicine Experience—Class Evaluation 2013 Please think about your entire experience at the Duke Integrative Medicine Center The session at the Duke Integrative Medicine Center: (may select more than one) 1. 2. 3. 4. 5. 6. 7.
Resulted in new Learning Was a good review Prompted self reflection Will change the way I practice Makes me want to investigate more about this topic Changed my perceptions on this topic None of the above
My comfort talking with patients about their use of CAM in a respectful and culturally appropriate manner is: 1. Completely comfortable 2. Moderately comfortable 3. Uncomfortable My comfort talking with all members of the interdisciplinary health team in a collaborative manner to facilitate quality patient care (including practitioners of healing systems other than allopathic medicine) is 1. Completely comfortable 2. Moderately comfortable 3. Uncomfortable My comfort utilizing principles of EBM in analyzing integrative medicine approaches, including databases, peer-reviewed publications, authoritative textbooks, web-based resources, and the experiential knowledge of CAM providers is: 1. Completely comfortable 2. Moderately comfortable 3. Uncomfortable I would refer a patient of my own to an Integrative Medicine specialist: 1. Yes 2. Not Sure 3. No Next year: (not multiple select) 1. This topic should be presented in this format 2. This topic should be presented in a different format 3. This topic should not be presented One thing I will take away from this session is: Did any of your peers positively or negatively impact your learning for this session? Who? Why? How could you have participated differently (to impact your learning or the learning of your peers)?
Mandatory Curriculum in Integrated Medicine
Table A1. Integrative Medicine Fair Offerings Domain (Section) Red
Green
Blue
Purple
Module
Maximum Students
Space
Set-Up Needs
Presentation Type
Acupuncture/TCM
10 Students
Workshop B
Portable massage table
Chinese herbals
5 Students
Chairs
Western herbals & supplements Ayurveda
5 Students
Consultation room A— 1225 Therapy room D
Chairs
5 Students
Consultation C
Chairs
Feldenkrais
10 Students
Workshop C— 1322
Demonstration, discussion and experiential
Integrative approaches to pain Reiki
8 Students 4 Students
Executive conf. room Fitness center
Need blankets/mats, chairs stacked in corner Chairs Chairs in room
Ergonomics
3 Students
Indoor meditation room
Ergonomic chair (Capsico chair from one of the clinic rooms)
Demonstration, discussion and experiential Demonstration, discussion and experiential
Integrative health coaching for sleep Yoga
5 Students
Consultation B
8 Students
Workshop A
Nutrition & healthy cooking Mindfulness meditation
8 Students
Nutrition Center —room 1404 Outdoor meditation room
Print-out articles from email Mats, straps, and eye pillows for each person TBD
Massage therapy
6 Students
Aromatherapy
8 Students
Quiet room— areas near water wall and bar Workshop D
Biofeedback
4 Students
Library
Integrative medicine research
4 Students
Therapy room F
Hypnosis
4 Students
Therapy room F
4 Students
REFERENCES 1. Barnes PM, Bloom B, Nahin R. Complementary and alternative medicine use among adults and children: United States, 2007. National Health Statistics Report, #12, 2008, pp. 1-24. Available at: http://www.cdc.gov/nchs/products/nhsr.htm.
Mandatory Curriculum in Integrated Medicine
Chairs in circle
Demonstration, discussion and experiential Demonstration and discussion Demonstration and discussion Demonstration, discussion and experiential
Discussion
Demonstration, discussion and Experiential Discussion and experiential Demonstration, discussion and experiential Discussion and experiential
Trash cans, antibacterial wipes and hand gel, and name tags
Demonstration, discussion and experiential
Set up AV, table to display info, set up chairs around table 4 Laptops loaded with the CDs and ear pieces Table to sit laptop on to view vide. Copies of handout. TBD
Demonstration, discussion and experiential Discussion and experiential Discussion
Discussion and experiential
2. Adler SR, Fosket JR. Disclosing complementary and alternative medicine use in the medical encounter: a qualitative study in women with breast cancer. J Fam Pract. 1999;48 (6):453–458.
EXPLORE September/October 2015, Vol. 11, No. 5 399
3. 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. 4. Association of American Medical Colleges. Medical school graduation questionnaire: all schools summary report. 1999–2012. Used by special permission. 5. Gaylord SA, Mann JD. Rationales for CAM education in health professions training programs. Acad Med. 2007;82(10):927–933. 6. Sierpina V, Bulik R, Baldwin C, et al. Creating sustainable curricular change: lessons learned from an alternative therapies educational initiative. Acad Med. 2007;82(4):341–350.
400 EXPLORE September/October 2015, Vol. 11, No. 5
7. Frenkel M, Frye A, Heliker D, et al. Lessons learned from complementary and integrative medicine curriculum change in a medical school. Med Educ. 2007;41(2):205–213. 8. Pearson NJ, Chesney MA. The CAM Education Program of the National Center for Complementary and Alternative Medicine: an overview. Acad Med. 2007;82(10):921–926. 9. Gaster B, Unterborn JN, Scott RB, Schneeweiss R. What should students learn about complementary and alternative medicine? Acad Med. 2007;82(10):934–938. 10. Epstein RM, Krasner MS. Physician resilience: what it means, why it matters, and how to promote it. Acad Med. 2013;88(3):301–303.
Mandatory Curriculum in Integrated Medicine
THE IMPACT
MANDATORY IMMERSION CURRICULUM IN INTEGRATIVE MEDICINE FOR GRADUATING MEDICAL STUDENTS OF A
Michelle L. Bailey, MD1 Saumil M. Chudgar, MD, MS2 Deborah L. Engle, EdD, MS3 Sam D. Moon, MD, MPH4 Colleen O'Connor Grochowski, PhD5 and Alison S. Clay, MD6#
Background: Although many Americans utilize complementary and alternative medicine (CAM) services and products, few medical school curricula consistently provide instruction in counseling patients on the use of CAM or strategies for identifying credible evidence on the safety and effectiveness of CAM therapies. Methods: This is a mixed methods study. A sustainable, mandatory, half-day CAM immersion curriculum for graduating medical students is described. Student comfort talking with patients about CAM, their willingness to refer patients to a CAM provider, and adequacy of the CAM curriculum was assessed. Results: Students who participated in this mandatory curriculum, rated the medical school curriculum in CAM as more
INTRODUCTION Use of complementary and alternative medicine (CAM) is prevalent among Americans. According to the 2007 National Health Interview Survey (NHIS) data, almost 40% of the US adult population is using CAM.1 CAM use is also present in pediatric populations with 12% of children having used CAM in the past 12 months.1 While many people are seeking CAM services, patients do not often disclose their use of CAM to physicians, and physicians do not generally ask patients about use or refer them for CAM therapies.2
1 Department of Pediatrics, Duke University School of Medicine, Durham, NC 2 Department of Medicine, Duke University School of Medicine, Durham, NC 3 Duke University School of Medicine, Durham, NC 4 Department of Community and Family Medicine, Duke University, Durham, NC 5 Curricular Affairs, Duke University School of Medicine, Durham, NC 6 Department of Surgery, Duke University School of Medicine, HAFS Building, 2301 Erwin Rd., Durham, NC 27710 # Corresponding Author. e-mail: [email protected]; [email protected]
394
& 2015 Published by Elsevier Inc. ISSN 1550-8307/$36.00
adequate than students at other medical schools without a mandatory curriculum. Students’ narrative comments indicate the curriculum impacts students knowledge about CAM, patient use of CAM, and personal practice with CAM in the future. Conclusions: The timing of the CAM curriculum near to graduation, students’ personal exploration of several CAM modalities through immersion, and student interaction with community CAM providers are aspects of the curriculum that make the curriculum successful and memorable. Key words: Complementary medicine, integrative medicine, alternative medicine, medical education, undergraduate (Explore 2015; 11:394-400 & 2015 Published by Elsevier Inc.)
In 1999, the American Association of Medical Colleges (AAMC) recognized the need for instruction in CAM in undergraduate medical education (UME) and performed a needs assessment.3 Of the 117 US medical schools surveyed about instruction in CAM, 64% offered curricula in CAM, but the majority were not mandatory.3 Overall, 63% of medical students reported that their medical school curriculum in CAM was inadequate on the AAMC's Graduation Questionnaire (GQ) in 1999.4 To address these needs, the National Center for Complementary and Alternative Medicine (NCCAM) awarded 15 R25 education project grants to academic institutions from 2000 to 2008 to develop curricular initiatives in integrative medicine.5 Barriers identified for developing and implementing CAM curricula into UME at the conclusion of these projects included competition for valuable course time, buy-in from faculty and institutional leaders, faculty development, and limited resources.6 Participants in these education projects described six components necessary for successful implementation of a CAM curriculum6,7: 1. Integration into the existing required curriculum, 2. Visibility—making CAM visible as an important component to the educational mission of the academic medical center, 3. Faculty development,
EXPLORE September/October 2015, Vol. 11, No. 5 http://dx.doi.org/10.1016/j.explore.2015.07.003
4. Leadership, 5. Accessible and reliable reference resources, and 6. Long-term sustainability. Studies published about the implementation of CAM curricula since the completion of the R25 education projects generally found the initiatives to be unsustainable or not able to reach a large group of medical students. We describe the successful implementation of a mandatory, half-day immersion in CAM for graduating medical students. This curriculum was not part of, nor was it supported by, an R25 education grant.
METHODS: DEVELOPMENT OF THE CAM CURRICULUM In 2005, a decision was made to add CAM instruction to the fourth year medical school curriculum at Duke University within the Capstone course, a mandatory course held two months prior to medical school graduation. The School of Medicine had recently revised its goals and objectives, and added objectives related to the introduction of CAM to the students. The first year of this curriculum, students attended a 90-min lecture on integrative medicine by faculty and staff at the Duke Center for Integrative Medicine. This event was held in an auditorium. In 2006, the event was moved to the medical center library, a space with greater flexibility and with lower ambient noise. The session was more interactive allowing students the opportunity to try several modalities of CAM. The event was moved to the newly opened Duke Integrative Medicine (Duke IM) Health & Healing Center in 2007, a space architecturally designed to promote contemplation and serenity, including incorporation of natural elements such as arched ceilings, curved walls, natural light, and the sound of cascading water. In 2008, the course was taken over by a new course director, and a new director for medical education at Duke Integrative Medicine, formerly the Duke Integrative Medicine Center, had been appointed. While the experience remained mandatory for all students, students were allowed to pick individual sessions of greatest interest. The timeline for these changes is depicted in Figure 1. The current curriculum consists of a one-hour seminar, “Introduction to Complementary and Integrative Medicine,” followed by an immersion experience. The interactive seminar provides core information (utilization rates of CAM by patients, risks vs. benefits, evidence-based resources, etc.) to begin to build a foundation of integrative medicine knowledge
Location
2005 Auditorium
Attendance
Mandatory
Material
Lecture
Pick modalities
None
and serves to orient students to the interactive fair that occurs later in the course. The Complementary and Integrative Medicine immersion, also called the Duke Integrative Medicine fair (IM Fair), occurs a few days after the didactic session. The fair lasts for four hours, and it is supported by over 30 providers including Duke Faculty, staff, and community CAM providers. Each student has the opportunity to experience four 40-min sessions in the field of integrative medicine such as nutrition, massage, acupuncture, yoga, and biofeedback. In many cases, this is the first time that students have an opportunity to interact directly with community CAM providers. Medical center library staff volunteer their time to serve as shepherds for the event, helping the 100þ students find their way to each of their assigned sessions. IM Fair sessions were originally organized around NCCAM's five CAM domains. As the classification for CAM changed, we recruited practitioners from the categories including: Whole Medical Systems, Integrative Medicine Health Care Models, Manipulative and Body-Based Practices, Mind–Body Medicine, and Self-Care & Lifestyle Practices. Students sign up for one experience within four different rotations; rotations allow for easy movement within the DIM building. The sessions offered each year vary based on availability of providers and ongoing feedback from students and providers. Recent additions include Integrative Approaches to the Patient with Pain and Integrative Oncology. Our last group of offerings is provided in Appendix A. Costs associated with the fair include materials (i.e., $250 for food for the nutrition sessions), a $3000 stipend to partially offset lost revenue at Duke Integrative Medicine (which closes the clinic during the student experience), and an appreciation luncheon for the faculty, staff, and community CAM providers who volunteer their time (total cost $1000). This appreciation luncheon offers “healthy nutrition” provided by an Executive Chef with an understanding of food as medicine and offers community providers an opportunity to network with each other. Faculty support comes from the School of Medicine and is provided as salary to the course director and administrator for the course; the IM Fair represents 10% of the Capstone course. We estimate that it takes roughly 40 h a year to organize, plan, and carry out the fair. Most of this time is dedicated to securing a date to close the center to patient care, recruiting faculty, and determining in which spaces to place those faculty (as different spaces in the building allow for smaller or larger groups of students).
2006 Medical Center Library Mandatory
2007 DIM Center
2008 to present DIM Center
Mandatory
Mandatory
Discussion and Experiential Assigned
Experiential
Experiential
Assigned
Students choose sessions they wanted to attend
Figure 1. Timeline of changes to curriculum.
Mandatory Curriculum in Integrated Medicine
EXPLORE September/October 2015, Vol. 11, No. 5 395
Faculty recruitment is our main concern each year. Durham, NC is a relatively small community with a modest number of providers of integrative medicine. However, our institution received funding from the Bravewell Collaborative from 2004 to 2012, allowing Duke Integrative Medicine to offer faculty development awards to physicians and mid-level providers for a distance-learning fellowship in integrative medicine through the University of Arizona. Many of the volunteer faculty are Bravewell Fellow alumni. Other volunteers work in direct patient care at Duke Integrative Medicine. Volunteers from previous years often offer suggestions for new faculty from within their professional networks. Every year, we retain about 75% of the volunteers. Sustainability is a concern given the need for volunteer faculty. We have held formal conversations with all the volunteers at the appreciation luncheon and informal conversations with individual volunteers before and after the fair (while the volunteers break down their stations). Faculty repeatedly state that they enjoy the opportunity to interact with so many students, to nurture their interest in their CAM fields, and to network with other providers in the local integrative medicine community. To further increase sustainability, we surveyed faculty, staff, and community CAM providers in 2014 to determine interest in participating in the IM fair on a weekend day. More than 75% were willing to continue to volunteer time on the weekend, allowing Duke Integrative Medicine to keep the clinic open for the full weekday, minimizing the loss of revenue.
METHODS: CURRICULUM ASSESSMENT This is a mixed methods study, including quantitative data from the AAMC graduate questionnaire (GQ) as well as qualitative and descriptive data from course evaluations completed by students within 24–48 h of the IM fair. Permission to use Data from the GQ questionnaire was obtained from the AAMC. Review of course evaluation data was submitted to the Duke University Institutional Review Board and considered exempt from further review. All graduating medical students complete the AAMC Graduation Questionnaire (GQ) that includes the question, “Do you believe that the time devoted to your instruction in Complementary and Alternative Medicine was inadequate, appropriate, or excessive?” Since the Capstone course is the last required component of the medical school curriculum and the only required experience in CAM, responses from Duke students were compared to those of other graduating students across the country from 2004 to 2013 using a z-test of proportions to ascertain whether the proportion of Duke students who reported inadequate instruction in CAM was different than national respondents on the GQ.4 Over the years, the course director has utilized several different course evaluations to evaluate the IM fair and the Capstone course. Questions on evaluations were changed when students' responses did not discriminate between lecturers or lecture topics. Pre–post knowledge testing was also removed from the course when student knowledge reliably increased immediately following a session. The one question considered to be most useful by the course director included a single open-ended question, “what will you
396 EXPLORE September/October 2015, Vol. 11, No. 5
Percentage of Graduang Medical Students Reporng Curriculum in IM is "inadequate" 45 40 35 30 25
*
20
*
Duke Naonal Average
15 10
*
*
2008
2009
*
*
*
5 0 2004
2005
2006
2007
2010
2011
2012
Figure 2. Proportion of students reporting CAM curriculum in medical school as inadequate. take away from the CAM experience?” This question was appropriate for students who had vastly different experiences during the IM Fair (yoga vs. nutrition). A qualitative analysis of students' responses on the IM fair evaluation from 2012 and 2013 was conducted to extract themes from this open-ended question. Based on initial qualitative analysis from 2012, the 2013 evaluation was modified to ask students specifically about their comfort talking with patients and CAM providers, their familiarity with principles of evidence-based medicine as it related to CAM, and their willingness to refer patients to CAM (Appendix B). RESULTS Since 2006, when the experiential component was added to the Duke Curriculum, there was a statistically significant difference (np o 0.05) in the number of Duke Students reporting that our medical school's curriculum in integrative medicine was inadequate, compared to the national average. This difference has been sustained since 2006 (Figure 2). More Duke students indicate that their curriculum in integrative medicine was adequate compared to the rest of graduating US medical students. Themes extracted from student comments on the required IM fair evaluation covered a breadth of topics that centered around three major themes: 1) Knowledge about CAM and CAM providers: understanding the breadth of CAM, new knowledge of a specific modality, treating the patient as a “whole” person, the presence or/absence of evidence-based medicine to support the use of CAM, and working with provide “The value of CAM in conditions, particularly pain but also insomnia and functional diseases.” “Integrative Medicine, at its heart, cares for the spiritual, nutritional, emotional and physical person…many parts that traditional medicine omits.” “There is more scientific research on these fields than I realized. Also, some of these treatments are not benign and do carry risks.”
Mandatory Curriculum in Integrated Medicine
2) Patient use of CAM: understanding who uses CAM and why, lack of insurance coverage for CAM “The prevalence of CAM usage was much higher than I thought.” “There are a lot of other options out there for treatment besides traditional medicine and my awareness of those will help better serve my patients who have symptoms refractory to traditional medical treatment.” “I think CAM is a great augment to medical care, but unfortunately, patient access to it is limited by cost and lack of insurance coverage.” 3) Personal practice (as both a patient and a future physician) related to CAM: the need to learn more about CAM, incorporating CAM into practice and/or referring patients to CAM, or using CAM for own self care) “How to present integrative medicine as a team effort— that works in synergy with one another and not against each other. The importance of communication between providers and how each provider could help the patient maximize his or her benefits from another provider.” “Having a personal understanding of some of the modalities of CAM, I will now be less apprehensive in considering CAM in the care of my patients.” “Related to self-care, the greatest take away from this experience is the value of meditation as a clinician. We need to take care of ourselves in order to take care of our patients. Learning how to combine relaxation and alertness requires practice, but it can result in greater focus and rapport in patient interactions.” On the 2013 student evaluation (n ¼ 79), 88.3% of students indicated that the IM fair resulted in new learning, 67.1% indicated that the fair prompted self reflection, 60% indicated that the fair resulted in a desire to learn more about CAM, and 52% said the fair changed their perceptions on CAM. At the conclusion of the fair, very few medical students felt uncomfortable with discussions about CAM (Figure 3).
DISCUSSION Over the past 10 years, we have built and sustained a successful curriculum in complementary and alternative medicine at our medical school. We attribute the success of our program, based Student Comfort with CAM 100% 80% 60% uncomfortable moderate comfort
40%
completely comfortable 20% 0% Talking with Paents
Talking with Praconers
Using EBM to analyze CAM
Figure 3. Student comfort talking with patients about CAM, talking with CAM providers and referring patients to CAM.
Mandatory Curriculum in Integrated Medicine
on students responses to the Graduate Questionnaire, and the students responses to open-ended questions on the IM Fair evaluations, to five aspects of the curriculum: (1) the timing of the program in the fourth year of medical school, (2) the immersive/experiential component of the curriculum, (3) the mandatory nature of our program, (4) the building space, and (5) a modest financial commitment from our institution. This curricular effort has been successful in part due to the timing of the Integrative Medicine fair within the fourth year curriculum. By this point in their training, students have learned the “essentials” of medicine. They are beginning to think about how they will practice medicine in internship and residency. Students seem willing to challenge pre-existing beliefs about medicine and develop personal practices with regard to complementary and integrative medicine. Having completed 3.75 years of medical school, students are aware of how physically and emotionally exhaustive medical training can be. They are interested in strategies for improving and supporting their own self-care throughout their medical career. The immersive nature of this event also contributes to its success. Instead of engaging students in academic argument, students are asked to participate in several modalities (Appendix A) and to consider how these activities might benefit themselves and/or their patients. The experiential nature of the event often informs those who previously were skeptical. The mandatory nature of this event is important. Like many other institutions, we have a CAM elective, but few students participate in this elective each year (limited to a maximum of four students). These students often already have interest in and positive attitudes towards CAM. Making this experience mandatory ensures student exposure to CAM and challenges students with preconceived, negative opinions about CAM. However, allowing students to pick modalities of greatest interest makes the experience more palatable to learners. These changes to the curriculum, adapted in 2008, made a noticeable, albeit not quite statistically significant, change on the GQ questionnaire. We are fortunate to have such a beautiful, committed space in which integrative medicine is practiced daily. The physical location sets the tone for the day; the minute the students enter this space, it is clear that this experience will be different than the high stress, high paced experiences at other times during medical school. While this is not possible for many academic medical centers, simply moving away from the central health system's location to a more quiet space may be adequate; we noticed a change when we moved to the Medical Center Library space in 2006. The sustainability of our curriculum has demanded modest financial support from the School of Medicine, dedicated time within the Duke Integrative Medicine facility, and a volunteer faculty consisting of Duke faculty, staff and community providers in complementary and alternative medicine. The breadth of experiences offered to the students and the providers' extensive experience is essential to the success of the IM Fair. The sheer number of offerings allows students to interact with a number of providers across a variety of CAM modalities and gives students' choice about their participation. Although we are anxious to recruit and retain faculty, we have not found this to be particularly difficult because the providers value the networking time during the appreciation luncheon.
EXPLORE September/October 2015, Vol. 11, No. 5 397
CONCLUSIONS AND FUTURE DIRECTIONS Future efforts for the Integrative Medicine fair will include a greater focus on resilience and adaptation for interprofessional education. The need to focus on resilience was identified through our qualitative analysis of student evaluation comments. Although, students described gaining knowledge about CAM and expressed increased willingness to talk with and refer patients to CAM—all objectives identified by previous CAM educators for students in allopathic medicine programs8,9—students also expressed an interest in utilizing CAM for their own benefit. In addition, there has been increased attention given the need to foster resilience among medical students within the medical community.10 Future IM fairs will promote discussion about use of CAM for self-care. We will also adapt the IM fair to include learners from several professions, including the professional programs for physical therapy, physician assistants and nursing at our institution. Since these professions often include differing emphasis on pain management, patient advocacy, and movement within their explicit curricula, including learners from these schools may improve collaboration and attitudes towards CAM. We hope to study these changes by comparing and contrasting student experiences between professions, including attitudes towards CAM, willingness to refer to CAM, and knowledge about the use of CAM for specific medical conditions (sleep disturbances, headaches, and depression). We will also add new questions about willingness to use CAM for self-care to the evaluations. Finally, our CAM providers have indicated, during formal discussion in the appreciation luncheon and informally before and after the sessions, that they would like to include additional time for networking during the fair. Many indicated interest in the skills of other providers and would like an opportunity to explore modalities other than their own during the fair. This networking would allow providers to refer patients to each other. Since providers already value the networking opportunity, we hope to add time at the start or end of the IM Fair to allow CAM providers to experience each other's practice and to survey providers more formally about their participation in the fair.
Acknowledgments
We would like to extend gratitude to all of the community CAM providers who have volunteered dozens of hours to this project over the years. These volunteers include a commitment of staff from the Duke Medical Center Library who facilitated the fair in 2006 and who remain involved after the sessions moved to Duke Integrative Medicine. The authors would also like to thank Rob Tobin, the course coordinator for the Capstone course for his tireless efforts at making the IM fair a success and Duke Integrative Medicine for their commitment to this project. Finally, we would like to acknowledge Ruth Wolever, PhD, who offered insightful editing and review of this article.
APPENDIX A For course evaluation from 2013, see Table A1.
398 EXPLORE September/October 2015, Vol. 11, No. 5
APPENDIX B. COURSE EVALUATION FROM 2013 Duke Integrative Medicine Experience—Class Evaluation 2013 Please think about your entire experience at the Duke Integrative Medicine Center The session at the Duke Integrative Medicine Center: (may select more than one) 1. 2. 3. 4. 5. 6. 7.
Resulted in new Learning Was a good review Prompted self reflection Will change the way I practice Makes me want to investigate more about this topic Changed my perceptions on this topic None of the above
My comfort talking with patients about their use of CAM in a respectful and culturally appropriate manner is: 1. Completely comfortable 2. Moderately comfortable 3. Uncomfortable My comfort talking with all members of the interdisciplinary health team in a collaborative manner to facilitate quality patient care (including practitioners of healing systems other than allopathic medicine) is 1. Completely comfortable 2. Moderately comfortable 3. Uncomfortable My comfort utilizing principles of EBM in analyzing integrative medicine approaches, including databases, peer-reviewed publications, authoritative textbooks, web-based resources, and the experiential knowledge of CAM providers is: 1. Completely comfortable 2. Moderately comfortable 3. Uncomfortable I would refer a patient of my own to an Integrative Medicine specialist: 1. Yes 2. Not Sure 3. No Next year: (not multiple select) 1. This topic should be presented in this format 2. This topic should be presented in a different format 3. This topic should not be presented One thing I will take away from this session is: Did any of your peers positively or negatively impact your learning for this session? Who? Why? How could you have participated differently (to impact your learning or the learning of your peers)?
Mandatory Curriculum in Integrated Medicine
Table A1. Integrative Medicine Fair Offerings Domain (Section) Red
Green
Blue
Purple
Module
Maximum Students
Space
Set-Up Needs
Presentation Type
Acupuncture/TCM
10 Students
Workshop B
Portable massage table
Chinese herbals
5 Students
Chairs
Western herbals & supplements Ayurveda
5 Students
Consultation room A— 1225 Therapy room D
Chairs
5 Students
Consultation C
Chairs
Feldenkrais
10 Students
Workshop C— 1322
Demonstration, discussion and experiential
Integrative approaches to pain Reiki
8 Students 4 Students
Executive conf. room Fitness center
Need blankets/mats, chairs stacked in corner Chairs Chairs in room
Ergonomics
3 Students
Indoor meditation room
Ergonomic chair (Capsico chair from one of the clinic rooms)
Demonstration, discussion and experiential Demonstration, discussion and experiential
Integrative health coaching for sleep Yoga
5 Students
Consultation B
8 Students
Workshop A
Nutrition & healthy cooking Mindfulness meditation
8 Students
Nutrition Center —room 1404 Outdoor meditation room
Print-out articles from email Mats, straps, and eye pillows for each person TBD
Massage therapy
6 Students
Aromatherapy
8 Students
Quiet room— areas near water wall and bar Workshop D
Biofeedback
4 Students
Library
Integrative medicine research
4 Students
Therapy room F
Hypnosis
4 Students
Therapy room F
4 Students
REFERENCES 1. Barnes PM, Bloom B, Nahin R. Complementary and alternative medicine use among adults and children: United States, 2007. National Health Statistics Report, #12, 2008, pp. 1-24. Available at: http://www.cdc.gov/nchs/products/nhsr.htm.
Mandatory Curriculum in Integrated Medicine
Chairs in circle
Demonstration, discussion and experiential Demonstration and discussion Demonstration and discussion Demonstration, discussion and experiential
Discussion
Demonstration, discussion and Experiential Discussion and experiential Demonstration, discussion and experiential Discussion and experiential
Trash cans, antibacterial wipes and hand gel, and name tags
Demonstration, discussion and experiential
Set up AV, table to display info, set up chairs around table 4 Laptops loaded with the CDs and ear pieces Table to sit laptop on to view vide. Copies of handout. TBD
Demonstration, discussion and experiential Discussion and experiential Discussion
Discussion and experiential
2. Adler SR, Fosket JR. Disclosing complementary and alternative medicine use in the medical encounter: a qualitative study in women with breast cancer. J Fam Pract. 1999;48 (6):453–458.
EXPLORE September/October 2015, Vol. 11, No. 5 399
3. 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. 4. Association of American Medical Colleges. Medical school graduation questionnaire: all schools summary report. 1999–2012. Used by special permission. 5. Gaylord SA, Mann JD. Rationales for CAM education in health professions training programs. Acad Med. 2007;82(10):927–933. 6. Sierpina V, Bulik R, Baldwin C, et al. Creating sustainable curricular change: lessons learned from an alternative therapies educational initiative. Acad Med. 2007;82(4):341–350.
400 EXPLORE September/October 2015, Vol. 11, No. 5
7. Frenkel M, Frye A, Heliker D, et al. Lessons learned from complementary and integrative medicine curriculum change in a medical school. Med Educ. 2007;41(2):205–213. 8. Pearson NJ, Chesney MA. The CAM Education Program of the National Center for Complementary and Alternative Medicine: an overview. Acad Med. 2007;82(10):921–926. 9. Gaster B, Unterborn JN, Scott RB, Schneeweiss R. What should students learn about complementary and alternative medicine? Acad Med. 2007;82(10):934–938. 10. Epstein RM, Krasner MS. Physician resilience: what it means, why it matters, and how to promote it. Acad Med. 2013;88(3):301–303.
Mandatory Curriculum in Integrated Medicine