Familiarity with Complementary and Alternative Medicine: A Multimodal Curriculum in Medical Education

Abstract

Purpose:

To identify whether exposing medical students to a multimodal curriculum of complementary and alternative medicine (CAM) practices improves their understanding of CAM clinical applications.

Background:

A significant portion of the U.S. population uses CAM: 34% of adults and 12% of children. Integrative medicine combines the best of conventional and CAM practices. Despite the increased clinical acceptance of CAM, medical education has been lagging, leaving gaps in learners' knowledge. It is important for medical education to keep pace with these developments by educating students and expanding the view of interprofessional care.

Methods:

A total of 101 first-year medical students at the University of Connecticut participated in a multimodal CAM curriculum. This included (1) an hour lecture, (2) an online research assignment for a continuity patient, and (3) 2 of 4 modules: acupuncture, hypnotherapy, Reiki, or pet therapy. Pre- and post-tests were administered 1 week apart to assess familiarity with CAM practices and the perceived safety and efficacy of each modality. The familiarity was rated on a scale of 0 (not familiar) to 10 (very familiar). Paired Student's t-tests assessed changes from pre- to post-tests at significant levels (p < 0.01).

Results:

Overall, the mean percentage of students who were able to identify 1 of the top 8 CAM modalities increased from 38% to 49%. The average familiarity rating of CAM significantly increased from 4.7 pretest to 6.6 post-test (p < 0.01). The top 8 CAM modalities, as selected by students, included acupuncture, meditation, yoga, massage, Reiki, chiropractic, hypnosis, and pet therapy. Overall, the familiarity ratings increased for both safety and effectiveness with intermodule variability from pre- and post-test (p < 0.01). Larger increases in effectiveness familiarity were found than of safety familiarity (p < 0.01).

Conclusions:

This multimodal curriculum significantly improved medical students' familiarity with CAM modalities and the perceived safety and effectiveness of the modalities.

Introduction

A significant portion of the U.S. population practices some form of complementary and alternative medicine (CAM). According to the 2012 National Health Interview Survey on use of complementary health approaches, combined data from >88,900 adults estimate that 34% of adults have utilized a complementary health care approach. ¹ The term complementary medicine refers to the combining of unconventional medicine with standard care, whereas alternative medicine refers to treatments used in place of standard care. ² By taking the best of standard care and the best of CAM practices and applying them collectively, we have the emergence of integrative medicine, which the Academic Consortium for Integrative Medicine and Health describes as whole person-focused evidence-based care. ³

CAM is used not only for self-care but also for prevention and treatment of disease and chronic disorders such as arthritis, digestive conditions, pulmonary problems, fatigue, joint pain and stiffness, allergies, and insomnia, often in combination with standard care. ¹ With a large portion of the population utilizing CAM, medical researchers have been called to action by the Institute of Medicine to examine CAM practices to increase not only scientific understanding but also help develop potential clinical applications. ⁴ Findings point to a need to optimize CAM training in medical school curricula as current education does not provide sufficient patient-centered CAM training. Even though a recent analysis of 130 U.S. medical school websites shows that 50.8% offer at least 1 CAM course or listing, most are focused on self-care and personal growth, with only 11% directed at interprofessional education activities involving interaction with CAM practitioners. ⁵

The increase in use of CAM has prompted a movement to support discussion between patients and physicians regarding potential CAM practices. As Bondurant states in the Annals of Internal Medicine, out of responsibility for the safety of their patients, health practitioners are being called upon to “bring these 2 worlds of contemporary medical practice together.” ⁶ Open communication between physician and patient about CAM practices will not only increase therapeutic efficacy but also help prevent unwanted side effects. However, an National Center for Complementary and Alternative Medicine/American Association of Retired Persons survey of adults 50 or older reports that only one-third of patients using CAM tell their physicians as they do not feel providers are well informed about CAM practices. ⁷ As stated by Gaylord in Academic Medicine, it is the responsibility of the health care professional to become “at least minimally knowledgeable about CAM” to strengthen the patient–doctor relationship and guide patients toward sound health care choices. ⁸

Open communication and increased partnership between patient and clinician, as well as between patient and CAM practitioner, help foster effective health choices that empower patients to take responsibility for their own health and lifestyle. ⁸ As such, future physicians would benefit from exposure to CAM modalities during medical school training to be equipped for open dialogue and discussion with patients regarding the safety and efficacy of CAM practices.

At the University of Connecticut (UConn) School of Medicine we designed a multimodal CAM curriculum as part of a required Clinical Medicine Course. Our aim was to evaluate whether this curriculum, with both didactic and experiential learning, would increase students' knowledge of different types of CAM practices.

Methods

Curriculum design

An institutional review board-approved multimodal curriculum was developed and included: (1) an hour lecture, (2) an online research assignment for a continuity patient, and (3) 2 of 4 hands-on/experiential activities: acupuncture, hypnotherapy, Reiki, or pet therapy (Fig. 1).

FIG. 1.

Study procedure. CAM, complementary and alternative medicine.

The course objectives included students' ability to define CAM and provide examples of various modalities as well as identify reputable resources for evaluating safety and efficacy. The goal of the online research assignment engaged each student to discuss the use of CAM seen at their continuity clinics. Students then shared their experiences on the various approaches to health and healing with their peers and faculty in the class. Group discussions would aid students in gathering online information regarding patient issues, as well as facilitate their skills in accessing reputable resources and evidence-based literature through the National Center for Complementary Medicine and Health, https://www.nccih.nih.gov/.

After the lecture, students rotated through CAM practitioner experiential sessions, including acupuncture, hypnotherapy, Reiki, or pet therapy. Core groups of 10 students each were established; each group was randomly assigned 2 of 4 CAM practitioner sessions that afforded the opportunity to observe, engage, and ask questions about practices.

Study design and sample

A total of 101 first-year UConn medical students participated. One week before the start of the curriculum, students were asked to complete a pretest to evaluate their baseline knowledge of CAM. One week after the lecture and experiential sessions, students completed post-test surveys. The mean age of the students was 25 years with a range from 21 to 41, and about 50% males and females from the registrar institutional database.

Measures

Pre- and post-test surveys included a set of questions assessing student familiarity with CAM practices, student perceived safety, and student perceived efficacy of each modality. Students were asked to list the “top 8” CAM modalities. The students were not given a specific definition for “top,” and were allowed to make their own interpretation. The selection of the “top 8” CAM modalities was based on each student's free response and students had the option to list any modality that came to mind. Students were then asked to rate on a scale of 0 (not familiar) to 10 (very familiar) their overall familiarity, perceived safety, and perceived effectiveness of each CAM modality. Three attitudinal items, including students' personal CAM interests, their likelihood to inquire about patients' CAM usage, and likelihood of encouraging CAM usage, were rated on a Likert scale of 1 (strongly disagree) to 5 (strongly agree). Paired Student's t-tests were used to assess the changes from pre- to post-test at significant levels (p < 0.01).

Results

The “top 8 CAM modalities,” as listed by UConn Health students, were acupuncture, meditation, yoga, massage, Reiki, chiropractic, hypnotherapy, and pet therapy.

After the experiential sessions, more students were able to identify at least 1 of the top 8 CAM modalities. Overall familiarity ratings increased from 38% pretest to 49% post-test with the largest increases seen in students' familiarity with Reiki, hypnosis, and animal-assisted pet therapy (Fig. 2). The average familiarity rating of CAM increased from 4.7 pretest to 6.6 post-test on a scale of 0 (not familiar at all) to 10 (very familiar) (p < 0.01). Familiarity ratings also increased for both safety and effectiveness of all 8 modalities from pre- to post-test (p < 0.01) with intermodule variability (Figs. 3 and 4).

FIG. 2.

Percentages of students' familiarity with the top CAM modalities, as listed by medical students, before and after completing the multimodal curriculum.

FIG. 3.

Mean scores of safety familiarity ratings for top CAM modalities listed by medical students before and after completing the multimodal curriculum. Note: *p < 0.05 from paired test to compare pre- and post-test ratings; **p < 0.01 from paired Student's t-tests to compare pre- and post-test ratings.

FIG. 4.

Mean scores of effectiveness ratings for top CAM modalities listed by medical students before and after completing the multimodal curriculum. Note: *p < 0.05 from paired test to compare pre- and post-test ratings; **p < 0.01 from paired Student's t-tests to compare pre- and post-test ratings.

For acupuncture safety, the pretest rating was 4.3 compared with a post-test rating of 5.7 (p < 0.01). For acupuncture effectiveness, pretest rating was 3.9; post-test 6.6 (p < 0.01). For Reiki safety, pretest rating was 4.8; post-test 7.1 (p < 0.01). For Reiki effectiveness, pretest rating was 1.9; post-test 5.5 (p < 0.01). For hypnosis safety, pretest rating was 3.4; post-test 7.8, (p < 0.01). For hypnosis effectiveness, pretest rating was 2.2; post-test 6.5 (p < 0.01). Comprehensive ratings of familiarity among all 8 measured modalities were significantly higher for overall effectiveness (6.0 pretest compared with 8.6 post-test). In terms of attitudinal questions, a slight increase in ratings of physicians' encouragement of CAM use (3.6 pretest compared with 3.8 post-test) was found significant (p < 0.01).

Discussion

Increased exposure to CAM through a multimodal curriculum may help students in the health professions understand how such modalities might improve patient care. One strength of the study was the large (101 students) participating population. Another strength was that the curriculum was a requirement, so the study queried individuals with and without an interest in CAM. Compared with similar studies from Duke University ⁹ and Mayo Clinic, ¹⁰ a unique aspect of our curriculum was the incorporation of clinical experience.

In addition to didactics, our model included real case discussions and clinical rotations with CAM professionals in an outpatient setting. Our innovative design better equipped the students to understand and respond to patients' needs in a real medical practice setting. A limitation of the study was that students were asked to list the “top 8 CAM modalities” and were not given a specific definition for the term “top.” Students may have listed modalities based on widespread use, exposure, popularity, or other personal reasons. Another limitation was that the CAM experiential modules were offered only during one afternoon; it would have been valuable to query students after longitudinal exposure to CAM modalities.

In addition, not all common CAM modalities were included in the curriculum. The curriculum was based on what was available locally for the experiential aspect; as such, there were several common modalities, such as aromatherapy, music therapy, art therapy, and expressive writing, which were not offered. Another limitation was that only first-year medical students from a single institution participated. Future curricular directions stimulated by our research findings include expanding the CAM experientials to second-year students with a potential focus on CAM for chronic illness. We may also conduct further research to examine how a longitudinal multimodal curriculum would affect students' clinical experience and impact patient care.

Conclusions

This required multimodal curriculum significantly improved students' overall knowledge of CAM modalities. The study demonstrated that perception of CAM modality safety and efficacy was modified by experiential learning and exposure. The perceived safety increased for all experienced CAM modalities, aside from meditation. Moreover, medical students gave higher efficacy ratings for all modalities after participating in hands-on CAM modules. Results indicate that this experience helped medical students feel more familiar with the modalities being used by patients. By adding more CAM hands-on sessions to the medical school curriculum, future physicians can learn how to help patients make informed decisions about CAM and how various modalities can impact and aid their health.