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No longer just an “alternative” in practice, integrative medicine is finding a home in U.S. medical education
Historically, the boundary between conventional medicine and complementary and alternative medicine (CAM) has been sharply drawn in the United States. Conventional medicine was evidence-based and practiced by physicians, nurses, and allied health professionals, while CAM—by definition—wasn’t. But as scientific data supporting CAM builds and its popularity among patients grows, the lines between the two sides are blurring. In light of these developments, more major medical schools are incorporating CAM into their curriculum.
You could call it the maturing of a movement that began in the late 1990s with the National Institutes of Health’s creation of the National Center for Complementary and Alternative Medicine (NCCAM). Over the years NCCAM’s funding has increased, and between 2000 and 2002 it awarded grants to a dozen medical schools interested in developing CAM education initiatives. Today, those schools continue to refine their approaches, and others have joined them in introducing CAM lectures and electives. Nearly 40 have banded together to make up the Consortium of Academic Health Centers for Integrative Medicine, which is actively working to integrate CAM into biomedicine through research and education.
While many concede that it is difficult to measure the effects of complementary and alternative medicine through Western-style research studies, there is ample evidence that at least some of these therapies work for at least some conditions. Even skeptics are being forced to recognize that, at a minimum, future physicians need to know enough to be able to discuss CAM with patients who are likely to be using it already (and may run the risk of dangerous herb-drug interactions).
But what has changed over the past five years is that medical schools are increasingly seeking a middle ground. Rather than accepting CAM on blind faith (“this therapy has been around for thousands of years, therefore it must work”) or rejecting it out of hand (“it’s all the placebo effect”) faculty are staking out a territory somewhere in between, says Dr. Brian Berman, Professor of Family Medicine at the University of Maryland Medical School and Director of the school’s Center for Integrative Medicine. “While there are still people who are polarized at these extremes, there is now enough clinical evidence to move us beyond focusing only on whether this therapy works for that condition and toward looking at how CAM relates to some of the broader issues and core competencies in medical education, such as empathy and doctor-patient communication.”
Redefining “alternative”
CAM education is riding a larger wave of change brought about by the spread of Internet-based consumer health information and the growing popularity of CAM therapies due to patient dissatisfaction with the current system. In a NCCAM survey conducted in 2002 in the U.S., 36 percent of adults said they were using some form of complementary and alternative medicine. When health-related megavitamin therapy and prayer were added, that number rose to 62 percent. Many people believe that percentage is even higher today. Berman argues that, as a consequence, what he refers to as “the paternalistic approach to medicine” is no longer acceptable. “People have more access to information and are looking for a partnership with their doctor. They want someone who can discuss the pros and cons of a particular therapy and how it would fit into their care,” he says—regardless of where it originated.
Even the terminology is up for debate. Dr. Michael Baime, Associate Professor of Medicine at the University of Pennsylvania Medical School and founder and director of the Penn Program for Stress Management, says that CAM education at his institution has gone through several distinct phases. In the early 1990s, he says, there was fear and resistance, followed by a period of interest and enthusiasm. But today, he says, the school simply draws less of a distinction between CAM and conventional medicine. "Whether something is alternative or not doesn't mean as much as it used to," he explains. "As therapies that were initially viewed as 'alternative' enter the mainstream, the distinction loses its importance. What matters more to doctors and patients is whether or not a specific treatment supports healing."
The University of Pennsylvania Medical School is not alone. It has been long argued that the term complementary and alternative medicine should be replaced with integrative medicine, to reflect its incorporation into conventional medicine and evidence base.
Dr. David Rakel, Assistant Professor of Medicine at the University of Wisconsin School of Medicine and Public Health, and director of the school’s integrative medicine program, argues that even this term is becoming outdated. "I believe down the road we will evolve to a focus on health and healing,” he says, adding that rather than focus on pathogenesis (the creation of suffering), medicine will focus on salutogenesis (the creation of health). This shift, he adds, could lead to all sorts of changes, such as decreasing technology dependence and creating “health-oriented teams” that work alongside “disease-oriented teams” to give patients optimal care.
Whether academic institutions are ready to embrace a new philosophy, or simply make more room for CAM in their courses, integration is rarely seamless or easy. Challenges include faculty resistance, an already overcrowded curriculum, a shortage of knowledgeable unbiased instructors, the effort required to stay abreast of up-to-date reliable sources of information, and the need to develop good teaching and assessment tools.
But none of these barriers are insurmountable. Here are six strategies that have helped early adopters gain acceptance and sustain momentum:
1. Know what to teach
The following three questions emerged as central to deciding which complementary and alternative medicine therapies students should learn, according to a survey of 15 U.S. NCCAM grant recipients published in the October 2007 issue of Academic Medicine:
- Is there significant scientific evidence for its efficacy or harm (for example, the interaction between St. John’s wort and many commonly used drugs)?
- Is there evidence that it is being widely used by patients (for example, mind-body techniques and acupuncture)?
- Does it have the potential to treat a medical condition for which conventional medical approaches are lacking (such as fibromyalgia, irritable bowel syndrom, chronic pain, and menopausal symptoms)?
2. Integrate complementary and alternative medicine into the existing curriculum
A main challenge integrators face is fitting CAM education into an overfull curriculum. One solution is to weave CAM values, knowledge, skills, and attitudes into existing courses, where appropriate, rather than create new courses. The University of Pennsylvania Medical School has been taking this approach for the past eight years, embedding mind-body medicine and acupuncture into courses on brain and behavior, rheumatology, and anesthesia and pain medicine. Meanwhile, at University of Maryland Medical School, students learn about integrative medicine in core courses, such as pharmacology and therapeutics for pain, and during the third-year clinical clerkship in family medicine.
3. Timing is everything
While it is important to introduce integrative medicine early to ensure sustainability, it's possible to start too early, says Rakel. He has seen many schools make this mistake, including one that introduced mind-body techniques during orientation, when students need to be more aware of new surroundings. It's better, he says, to teach students techniques for stress management later when they realize its potential benefit, once they're immersed in the stresses of academic life and exams.
4. Continually develop faculty
NCCAM grant recipients surveyed in Academic Medicine agreed that providing early and frequent opportunities for faculty to learn about integrative medicine is a key factor to success and sustainability. Educators we interviewed agreed. “A shortage of faculty leaders and mentors is a barrier, but we are overcoming it slowly through our fellowship and educational programs,” says Berman. Forms of training may include providing access to reliable sources of information, mini-sabbaticals, consultations, distance learning, and continuing medical education. But because faculty development takes time and patience, Rakel recommends concentrating the bulk of these efforts on faculty members who are already receptive. Those who are set in their ways, he says, not only are unlikely to change but will probably be annoyed by your efforts.
5. Emphasize assessment skills
But because the evidence is evolving and changing all the time, it is equally important for students to be ale to search and evaluate the literature themselves, educators say. At University of Maryland Medical School, says Berman, students are given an overview of therapies but are also taught to make their own decisions based on a critical appraisal of the data. “We are graduating residents and fellows who want to be able to intelligently discuss the strengths and weaknesses of these therapies with their patients.”
6. Experiential mind-body lectures and electives
The most effective strategy for teaching some forms of integrative medicine is to put students in the patients’ shoes. “You can read eight books, but until you receive a therapy you don’t really understand it as well,” says Rakel. More than 50 universities across the country are teaching mind-body practices and reflection in a course in relationship-centered care offered as an elective to first- and second-year medical students. Called “The Healer’s Art,” it was designed by Dr. Rachel Naomi Remen, Professor of Family and Community Medicine at University of California at San Francisco School of Medicine, to reinforce the “human dimensions” medical practice, prevent burnout, and help students find personal meaning in their professional work.
--Written by Natalie Engler for Harvard Medical International
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