Published in the February 2012 AAMC Reporter
By Whitney L.J. Howell
At first glance, Megan Wolf believed the man in front of her had been mortally wounded. She was horrified, until he looked up and laughed.
“I gasped, but he giggled at my reaction,” said the third-year student at the University of Pittsburgh School of Medicine. “He said it didn’t hurt at all and that he never felt better than after one of those treatments.”
What Wolf, who is the chair of the American Medical Student Association’s (AMSA’s) Wellness and Student Life Committee, saw—and what the man experienced—was a high-velocity, low-amplitude spinal adjustment. In essence, the chiropractor cracked his neck.
Witnessing this episode was part of Wolf’s introduction to complementary and alternative medicine, or CAM. Also known as integrative or mind-body medicine, these therapies are becoming more common in U.S. medical education.
The push to bring CAM into medical training began in 1999 when the National Center for Complementary and Alternative Medicine (NCCAM), part of the National Institutes of Health, launched the CAM Education Project.
Initially, the center awarded 14 grants of $1 million to $1.5 million to medical schools, teaching hospitals, and AMSA for research projects, such as training pediatric residents on the benefits of CAM in treating childhood diseases or teaching students to communicate effectively about it with patients. Today, a group of more than 50 U.S. and Canadian medical schools and teaching hospitals, called the Consortium of Academic Health Centers for Integrative Medicine, includes CAM in its curricula.
Although opinions about CAM are heated, there is no question that patients use it. According to 2008 data from the Centers for Disease Control and Prevention, nearly 40 percent of adults and 12 percent of children use at least one therapy, and many are reticent when it comes to telling their doctors. The substantial size of this group makes it vital that medical students understand how nontraditional therapies or supplements interact with standard medical care, said Aviad Haramati, Ph.D., a Georgetown University School of Medicine physiologist, who pioneered CAM education at Georgetown in 2000.
“We aren’t educating CAM practitioners,” he said. “But we are giving medical students knowledge so they can talk with their patients in an open-minded way from informed positions, and educate them on the potential risks of mixing complementary techniques or herbal supplements with prescription medications.”
The growing body of evidence-based research supporting CAM in peer-reviewed journals, such as the Annual Review of Medicine and the Journal of the American Medical Association, means academic medicine cannot ignore these modalities, Haramati added.
Opposition to CAM in Curricula
But not everyone in academic medicine agrees that medical students should learn about CAM. Steven Salzberg, Ph.D., medicine and biostatistics professor at Johns Hopkins University School of Medicine, openly opposes integrating CAM into medical education curricula, asserting that alternative modalities are ineffective.
“Whatever term is used—alternative medicine or integrative medicine—this isn’t medicine. At best, these are hypotheses,” Salzberg said. “Over 20 years, NCCAM has spent more than $1 billion, and [there is] no strong evidence that these activities work.”
He also criticized the propensity in academic medicine to group meditation and yoga with acupuncture, chiropractic, and homeopathic treatments. Clear evidence exists to support the efficacy of meditation and yoga, he said, and equating them to other modalities is erroneous.
Despite his objections to including CAM in curricula, Salzberg agreed it could be useful to train physicians proactively about treatments patients might seek on their own.
Challenges to Teaching CAM
Salzberg’s objections have not slowed the integration of CAM into education, but that does not mean getting buy-in for course additions has been easy. There are three main questions about this fusion, said Victor Sierpina, M.D., a professor in the integrative medicine program at the University of Texas Medical Branch in Galveston.
“The biggest concern is people’s unfamiliarity with the evidence behind CAM,” he said. “Once they become aware of peer-reviewed research, the resistance to including these topics drops. The same is true for administrators, faculty, and students.”
Many institutional leaders want details about how faculty will teach CAM from the evidence-based perspective, he said, and they want to know how this knowledge will augment training and turn students into lifelong learners.
Even with these questions satisfied, CAM remains divisive, said Michelle Bailey, M.D., a Duke University School of Medicine pediatric integrative medicine physician. She is also the director of medical education for Duke Integrative Medicine.
“Increasing CAM in allopathic medical training can still be considered controversial,” she said. “But there are many in the consortium who are looking for best practices, as well as the best ways to translate it to medical students.”
Current Course Curricula
Many medical schools and teaching hospitals have elaborate programs featuring CAM. For example, Haramati said, Georgetown launched a five-year program in 2005 for students to earn a master’s in CAM before pursuing their medical degree. The first degree program of its kind includes, among other topics, nutrition, mind-body skills, and CAM use in oncology.
“We brought acupuncture into anatomy and neuroscience, biofeedback into physiology, and the science of stress reduction into endocrinology,” Haramati said. “We want students to experience the mind-body connection firsthand and understand more about themselves.”
At Texas, students receive an orientation to the library that includes case-based information about herbal supplements as well as other CAM strategies, Sierpina said. Second-year students discuss chiropractic and massage in musculoskeletal classes, and others participate in grand rounds about the interaction between over-the-counter supplements and anesthesia. CAM is quickly becoming a fluid part of the curriculum, he said.
“It’s mostly invisible. It’s seamless,” Sierpina said. “We use problem-based learning to train students, and we want them to evaluate all possibilities. When treating a patient, CAM might not be the solution, but we want them to consider all options.”
But medical education is cramped, and many worry adding CAM-focused courses could overwhelm students.
To overcome this barrier, many institutions follow Texas’ example, infusing CAM theories into existing classes. For example, Duke offers two-week elective courses that give second-year students a solid foundation in CAM, Bailey said.
In addition to attending lectures, students meet CAM providers, such as acupuncturists, massage therapists, or health psychologists, and shadow these providers at the Duke Integrative Medicine building.
“It’s important for students to learn the credible information around integrative medicine so they can point patients to reliable sources,” Bailey said. “If, as patient advocates, we are to first do no harm, then we must be armed with information to educate patients and keep them safe.”
Duke students also learn about CAM during their required fourth-year capstone course. As part of this class, the school holds a four-hour integrative medicine health fair bringing in nearly 40 CAM providers from the community. Students visit booths, asking questions and gathering information. A lecture series several days before the fair also presents basic CAM details.
Medical students know patients benefit when their providers understand CAM, but students also see value for it in their own lives, said AMSA’s Wolf.
“AMSA participants focus on their wellness,” she said. “Our members look at natural things like yoga to handle the stress and pressures of medicine. These things help us take better care of ourselves so we can be better physicians.”
David Darrow, a fourth-year Texas student, agreed that studying CAM gives him empathy for how patients choose to approach their health.
“It’s ironic. As medical students, we approach our education as scientists who make decisions on evidence and fact,” he said. “But learning about CAM has really led me back to the humanistic part of medicine.”
To read the article at its original location: https://www.aamc.org/newsroom/reporter/feb2012/273812/therapies.html