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Institute of Medicine (US) Committee on the Use of Complementary and Alternative Medicine by the American Public. Complementary and Alternative Medicine in the United States. Washington (DC): National Academies Press (US); 2005.

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Complementary and Alternative Medicine in the United States.

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8Educational Programs in CAM

CAM IN HEALTH PROFESSIONS EDUCATION

Along with the growth in the integration of CAM and conventional medicine in health care institutions and individual practices, the number of health professional education programs that are teaching CAM is also growing. Park (2002) writes, “The exploration of complementary and alternative medicine topics in the medical school curriculum helps to elucidate the complex and uncertain nature of medical practice, sharpens skills for clinical decision-making, increases cultural sensitivity, and provides ideas for future research.”

In 1995 the Alternative Medicine Interest Group of the Society of Teachers of Family Medicine surveyed U.S. medical school departments of family medicine and all family medicine residency programs to determine the extent to which CAM was being taught in medical schools. The results showed that in 1995 CAM was taught in 34 percent of U.S. medical schools and 28 percent of family practice residency programs. The number of medical schools offering courses on CAM-related topics rose from 45 of 125 schools in the 1996–1997 academic year to 75 schools in 1998 (Wetzel et al., 2003) and 98 medical schools in the 2002–2003 academic year (Barzansky and Etzel, 2003).

To gather information about the specific topics being taught and the objectives behind the instruction, Brokaw et al. (2002) surveyed 123 CAM course directors at 74 U.S. medical schools. They found that the most typical course was an elective and that most of the courses (78.1 percent) were taught by CAM practitioners or by those who prescribe CAM therapies.

Burman (2003), in a survey of family nurse practitioner program directors, found that 98.5 percent of the 141 respondents reported that their programs included CAM-related content and that most of these (80.3 percent) integrated the CAM content into existing courses. A survey of 627 medical school, school of nursing, and college of pharmacy faculty and students at the University of Minnesota found that 88 percent of the faculty respondents and 84 percent of the students believed that CAM should be included in their schools' curricula (Kreitzer et al., 2002). Biofeedback, massage, and meditation were the therapies most likely to be used by the faculty from all schools.

A study of schools of pharmacy conducted by Dutta et al. (2003) found that 73 percent (46 out of 64 respondents) of schools were offering instruction in CAM, although courses on CAM were not yet mandated by the schools. The most frequently taught content area was herbals (45 schools). Table 8-1 shows the number of schools teaching various modalities. The National Association of Boards of Pharmacy, in a memorandum to all pharmacy school deans, stated that herbal products and nutraceuticals would be included in the North American Pharmacist Licensure Examination (NAPLEX).

TABLE 8-1. CAM Modalities Taught at U.S. Schools of Pharmacy (n = 46).

TABLE 8-1

CAM Modalities Taught at U.S. Schools of Pharmacy (n = 46).

These data indicate that much CAM-related education is being taught in the schools of the conventional health professions; however, the specifics of that training and a good understanding of the total extent of the training in CAM remain unknown.

Why Teach CAM?

At present, integrative medicine is largely market-driven and spans the spectrum from evidence-based practices that benefit patients and carry little risk to outright quackery, sometimes with significant risk. Without involvement on the part of our profession, we leave patients uninformed and without medical guidance.

(Gaudet and Snyderman, 2002)

The Institute of Medicine (IOM) report Health Professions Education: A Bridge to Quality (IOM, 2003) proposed the following vision for health professional education: “All health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches and informatics.”

To meet the challenges facing health professional education, the IOM report (2003) proposed a set of core competencies that all health clinicians should possess. The first of these is the ability to provide patient-centered care. To provide patient-centered care, the report states, health professionals must share power and responsibility with caregivers; communicate with patients in a shared and fully open manner; take into account patients' individuality, emotional needs, values, and life issues; implement strategies for reaching those who do not present for care on their own, including health care strategies that support the broader community; and enhance prevention and health promotion. Although that IOM report was referring to conventional medicine, the same competencies apply to CAM.

Given that CAM is widely used by the U.S. population, health care professionals need to be informed about CAM and knowledgeable enough to discuss the CAM therapies that the patient is using or thinking of using to more effectively communicate with their patients. Consistent with this view, a report of the American Association of Medical Colleges emphasized the importance of physicians being “sufficiently knowledgeable about both traditional and non-traditional modes of care to provide intelligent guidance to their patients” (AAMC, 1998). Gaudet (1998) maintains that to achieve the best medicine possible, physicians need to know both the CAM practices that have the potential to harm or be ineffective and knowledge of which CAM practices that, “when critically and intelligently integrated into health care, could be of benefit to patients.”

An article by Marcus (2001), in which the author took issue with some of the criticisms of conventional medical education (e.g., that physicians ignore mind-body interactions and disease prevention), concludes that medical students should receive evidence-based education about CAM, stating,

Without additional education about alternative medicine, physicians cannot obtain accurate information from patients about their use of alternative modalities, or provide information and guidance…. physicians must assist patients in making informed choices about health care, and they should be receptive to discussing alternative medicine with patients who request information. Physicians should be especially sensitive to the needs of patients with intractable medical conditions, such as cancer, chronic pain, and degenerative neurologic diseases, who seek relief and hope in alternative therapies.

As mentioned above, the IOM report on health professions education (IOM, 2003) described taking “into account patients' individuality, emotional needs, values, and life issues” as one aspect of patient-centered care. To meet this goal, both conventional health care professionals and CAM practitioners need to learn about the CAM therapies that are in use among the many cultures and ethnic groups that make up the U.S. population. Konefal (2002) writes that “understanding the cultural and political as well as the medical relevance of CAM modalities will allow the physician to respond more appropriately to his or her individual patients.” Although much of the preceding discussion relates to physicians, it can be applied equally to several health professions, including nursing, pharmacy, and dentistry.

Disch and Kreitzer (2003) suggest that because CAM is used prominently in health care, “education of nursing staff about the therapies and their indications for use is essential.” Park (2002) presents four additional arguments for teaching CAM in conventional health professions education:

  1. Medical schools are defining the mission of health care in progressively broader terms that are conceptually similar to those embraced by the integrative medicine movement. (See Chapter 7 for a discussion of an ecological approach to health.)
  2. Clinical decision making requires the ability to deal with uncertainty, and the same skills are needed to assess all therapies whether they are identified as conventional medicine or CAM.
  3. There is growing societal interest in diversity, and training in CAM increases cultural competence.
  4. As the boundaries of the medical sciences grow and more knowledge is accrued, the exploration of therapies currently identified as CAM will help direct productive biomedical, psychological, and sociomedical research agendas.

Few today would argue against the fact that health professionals must be knowledgeable about CAM in order to best serve the interests of their patients. The difficulty comes in attempting to decide what should be taught and how to fit such teachings into already crowded health professional educational curricula. The next section explores ideas about what should be taught about CAM to conventional medical practitioners.

Deciding What to Teach

The incorporation of CAM training into the curriculum of health professional education is not consistent, nor do guidelines exist on what content might be appropriate in such education. Grollman (2001) asserts that education about CAM should be evidence based and should not include teaching of unproven therapies. Even though evidence of effectiveness exists for some CAM therapies (see Chapter 5), most CAM therapies have only fairly recently been subjected to Western methods of scientific inquiry. As discussed elsewhere in this report, however, it is also the case that the effectiveness of many conventional medical therapies taught in medical school have also not been validated through randomized controlled trials (RCTs). Ezzo et al. (2001) found that only 40 percent of conventional medicine that had been tested by RCTs had positive or possibly positive effects.

Chapter 3 discusses the kinds of evidence that various decision makers use to make decisions. Researchers, for example, rely most heavily on studies with strong research designs, plausible biological mechanisms, the consistency of findings from study to study, and dose-response relationships. Although individuals who train new conventional practitioners require evidence of treatment effectiveness to decide how to train students, they also draw heavily on their own experience in deciding which treatments are effective and which ones are not. This is consistent with the recommendations in the IOM report on health professions education (IOM, 2003). That report took the position that education should “integrate best research with clinical expertise and patient values for optimum care, and participate in learning and research activities to the extent feasible.” Therefore, if the decision about what to teach is not based solely on the results of RCTs, on what other basis might one decide what should be taught about CAM?

The White House Commission on Complementary and Alternative Medicine Policy (2002) recommended, “The education and training of CAM and conventional practitioners should be designed to ensure public safety, improve health, and increase the availability of qualified and knowledgeable CAM and conventional practitioners and enhance the collaboration among them.”

Berman (2001) writes that “great heterogeneity exists in the content, format, and requirements of complementary and alternative therapy courses for medical students and physicians in training” and recommends that a consensus be developed about the essentials of a core curriculum. Ezzo et al. (2002) discussed their concerns about the lack of an evidence-based perspective in courses taught about CAM and suggested that The Cochrane Library would be an excellent tool for addressing this concern. Wetzel et al. (1998) made a number of suggestions for how CAM should be taught in health professional schools. These include the need to

  1. focus on critical thinking and critical reading of the literature;
  2. identify thematic content and express the chosen topics in clear, concise learning objectives;
  3. include an experiential component;
  4. promote a willingness to communicate professionally with CAM clinicians; and
  5. teach students to talk with patients about alternative therapies.

Konefal (2002) writes that education in CAM should include the reasons why patients use CAM, issues of efficacy, the limits of science-based approaches, legal and ethical considerations, and the role of spirituality in health and healing. Frenkel and Arye (2001) suggest that a CAM curriculum should include sufficient information about CAM therapies to prepare physicians to “help patients understand the overwhelming amount of information (and misinformation) about CAM.…” Brokaw et al. (2002) suggest that teaching of CAM should

  1. emphasize a critical evaluation of the scientific literature,
  2. enlist the involvement of basic science departments, and
  3. avoid advocacy of unproven therapies.

Kligler and colleagues (2000) reported on a set of guidelines for the inclusion of CAM in family practice residencies developed by the Society of Teachers of Family Medicine Group on Alternative Medicine. The guidelines include understanding and respect for different health beliefs and choices, the underlying theory of different CAM modalities indications and potential adverse effects of these treatments, and evidence of the efficacy and the cost-effectiveness of the therapies.

The Education Working Group of the Consortium of Academic Health Centers for Integrative Medicine has developed a set of curriculum guidelines in integrative medicine for use by medical schools. The guidelines delineate competencies in knowledge, attitudes, skills, and values

in keeping with the recent trend in all of medical education to reaffirm and re-emphasize the humanistic values at the core of medicine—training in integrative medicine should incorporate philosophical perspectives in addition to knowledge base and therapeutic skill in order to clearly underscore the relevance of human experience and interactions in health and medicine.

(Kligler et al., 2004)

The authors of the consortium guidelines emphasize that each school must develop its own specific content of courses needed to achieve competency in these areas, and they urge the development of innovative educational approaches that go beyond the teaching of scientific facts. These approaches include

  • experiential approaches to facilitate an understanding of CAM,
  • education of medical students in self-care and reflection, and
  • faculty development programs to produce educators who both have knowledge and skills in integrative medicine and recognize the importance of self-care and reflection in medical education and practice.

There is also no firm agreement about how CAM-related education should be included in nursing schools. Barbato Gaydos (2001) recommends that any plan to include CAM in curricula “should begin with identification of the educational purposes for that inclusion.” Cuellar et al. (2003) believe that the objectives for an educational program for nurses and other health care providers should include improvements in assessment skills so that they are able to identify CAM use in patients; legal and ethical considerations; and an examination of personal biases and beliefs about CAM. Parkman (2002) recommends that the goals of training registered nurses should include

  • assessment of the use of CAM, including risk factors associated with misuse;
  • identification of patient and family understanding of the therapies that a patient is using or planning to use;
  • identification of patient and family teaching needs related to CAM therapies; and
  • documentation of achievement of the goals listed above.

Reed and colleagues (2000) assert that prelicensure students must learn about the concepts behind CAM therapies as well as develop the ability to elicit and evaluate patients' use of these therapies. Richardson (2001) believes that a major challenge in designing educational programs will be to develop practitioners who are both well prepared and confident in their own practices but also open to other perspectives and therapeutic approaches.

In exploring what to teach about CAM in conventional medical education, the committee is sensitive to the concern expressed by some CAM practitoners that education about CAM should include respect for the length and rigor of training required for CAM professions. The committee is not suggesting that knowledge about CAM provided in the context of conventional medical education is the equivalent of education necessary to become a licensed CAM professional. An individual who takes one course during conventional training about massage, for example, does not have the expertise of a licensed massage therapist.

As can be seen from the preceding discussion, there is no consensus on what should be taught about CAM to conventional medical practitioners. Common elements appear to include critical thinking and assessment, with the inclusion of an experiential component. The following section discusses approaches to education on CAM taken by different conventional health professions schools.

Approaches to Curriculum Development

Health professional schools have taken a variety of approaches to providing education about CAM therapies. Milan et al. (1998) described a general internal medicine residency program that was implemented at Rhode Island Hospital and Brown University School of Medicine. The program includes didactic sessions in acupuncture, chiropractic, and massage therapy and an elective clinical experience. The overall popularity and use of the modality, as well as access to interested and qualified practitioners, were the most important factors in determining which CAM therapies were included. The criteria used to select the CAM practitioners who participated in the program included “the degree of experience and licensure in their particular field, communication style, clinical practice arrangements (both in terms of practice layout and patient population), and openness to traditional medical practices.”

The University of Arizona has developed the Program in Integrative Medicine which includes an associate fellowship program, required courses and electives in the College of Medicine, a continuing education program, and a research program. Breda and Schulze (1998) describe a capstone course for registered nurses in which students select a CAM therapy, experience it, provide a report that includes its physiological and scientific bases, and discuss how it might be incorporated into nursing practice.

The National Center for Complementary and Alternative Medicine (NCCAM) at the National Institutes of Health (NIH) has funded 15 CAM education projects at U.S. medical and nursing schools (Table 8-2). The aim of these projects is to design new educational approaches to the incorporation of information about CAM into the curricula of medical, dental, nursing, and allied health professional schools as well as in residency training programs and continuing education courses.

TABLE 8-2. CAM Curriculum Development Projects Funded by NCCAM.

TABLE 8-2

CAM Curriculum Development Projects Funded by NCCAM.

The program developed by the University of Minnesota involves curriculum development projects in the medical and nursing schools as well as the College of Pharmacy. One of the first efforts in all three health professional schools was to develop core competencies. Additionally, faculty and students were surveyed for their attitudes about CAM. Several changes were made in the medical school curriculum, including the addition of seven 2-hour sessions in one course related to designing integrated systems of care, traditional chinese medicine, manual therapies, and spirituality. Another course includes information on interviewing and assessing CAM therapies; a pharmacology course includes information on botanical therapies; self-care is included in a required surgery clerkship; and the 3-week clinical elective in integrative medicine was expanded.

The curriculum designed for the School of Nursing of the University of Minnesota addresses both undergraduate and graduate education. A broad spectrum of information about CAM has been systematically integrated into many courses, and there has been an emphasis on faculty development. Students completing the programs are required to be able to encourage patients to speak openly about their CAM use, to assess the safety and efficacy of selected CAM therapies, and to advise patients from an evidence-based perspective. The College of Pharmacy teaches its students about herbal medicine and nutritional supplements through both didactic lectures in required courses and an integrative care rotation in which students participate in natural products compounding. The university has also developed online CAM modules on several topics (e.g., introduction to complementary therapies and healing practices; spirituality and health; and culture, faith traditions, and healing) and offers a graduate minor in complementary therapies and healing practices in which students can choose from more than 35 courses.

The Rush-Presbyterian-St. Luke's Medical Center program is designed to integrate CAM therapies into the undergraduate and graduate curricula of the Rush University College of Nursing and to provide continuing education in CAM for both faculty and practicing nurses. Five competencies for undergraduate education in CAM were identified:

  1. Incorporate the assessment of patient use of CAM practices into standard history and physical examinations.
  2. Describe the indications and safety issues for selected CAM therapies.
  3. Demonstrate knowledge of the research or evidence base that supports the safety and efficacy of selected CAM therapies.
  4. Apply knowledge of the safety, efficacy, and appropriateness of CAM therapies to patient care management.
  5. Acquire a knowledge for working in a collaborative manner with CAM practitioners.

This program has also developed four basic required modules considered essential for all master's students. These modules are CAM Overview, CAM Assessment, Ethics and Clinical Decision Making, and CAM Practices and Qualifications of CAM Practitioners. An advanced pharmacology course also offers essential CAM-related content and five case-based modules have been developed to teach about CAM therapies for depression, low back pain, treatment of culture-specific illnesses, the management of pediatric asthma, and the management of stress and anxiety.

The Tufts Program in Evidence-Based Medicine plans to teach about several areas of CAM, including nutrition and pain, palliative, and supportive care. In addition, through its affiliation with the New England School of Acupuncture, it will also teach about East Asian Medicine.

Several changes were incorporated into the University of Michigan Medical School curriculum to teach medical students about CAM. Conventional and CAM practitioners participate in an 8-hour CAM Course Unit for first-year students that focuses on patterns of CAM use, identifying key issues for CAM researchers and practitioners, and classifying CAM modalities. The school also has a required course on alternative approaches to the treatment of musculoskeletal pain, as well as a course that offers an introduction to macronutrients and nutritional assessment and a mind-body theory and practice course. Fourth-year students are offered a 4-week clinical elective in CAM, and they may also enroll in a course addressing the scientific basis of CAM that meets the school's science in clinics requirement.

The Oregon Health and Science University is part of a CAM consortium that has designed the Oregon CAM Course, the mission of which is to develop CAM literacy and cognitive flexibility in conventional health professional students. The other members of the Consortium are the Oregon College of Oriental Medicine, National College of Naturopathic Medicine, and the Western States Chiropractic College. First-year students receive an introduction to education in CAM professions, as well as education in mind-body training, ethics, drug-herb interactions, how to assess the CAM literature, and simulated patients. Electives are offered in integrative medicine, healer's art, and mind-body skills.

The University of Washington School of Medicine and Bastyr University (a leading school for naturopathic medicine in Seattle, Washington) are cooperating to develop and integrate CAM training into the medical school. They began by identifying what they believed to be essential CAM content for all medical students and also designed cases to use for clinical teaching and assessments. Furthermore, they have implemented CAM content into several courses including

  1. Introduction to Clinical Medicine I and II
  2. Problem-Based Learning
  3. Medicine Health and Society
  4. Systems of Human Behavior I and II
  5. Pharmacology I and II
  6. Urinary System
  7. Nutrition
  8. Microbiology
  9. Anatomy
  10. Reproduction
  11. Endocrine

Although the preceding discussion has briefly described a few of the approaches being taken to teach CAM what is actually included in a CAM program depends on the goals and objectives of the individual educational institutions. The committee believes that it is important that the schools of health professions include information about CAM in their required curricula so that health care practitioners will be able to inquire about their patients' use of CAM in a way that is nonjudgmental and that allows health care practitioners to advise their patients about the use or avoidance of CAM therapies on the basis of the available evidence.

The next section addresses two of the more important educational issues for CAM practitioners.

EDUCATING CAM PRACTITIONERS

Much has been written about the inclusion of information about CAM in health professions education. Concomitant examination of education for many of the education programs for CAM practice areas is also important. Within and across CAM modalities there is tremendous variability in education and training of practitioners. Licensing requirements vary from state to state, but state statutes require a specified level of education for the licensed CAM professions (chiropractic, naturopathy, massage therapy, homeopathic medicine, acupuncture, and oriental medicine). For example, chiropractors (who are licensed in all states) must graduate from an accredited chiropractic college, pass national board examinations, and complete state licensing board examinations (Chapman-Smith, 2001). Naturopathic physicians are licensed in 13 states plus the District of Columbia, Puerto Rico, and the U.S. Virgin Islands. Individuals must “have 4 years of naturopathic medical school, which includes course work in basic science, pathophysiology, treatment, and 2 years of clinical experience in an outpatient setting” (Stretch, 2001). Passing the Naturopathic Physician Licensing Examinations enables those who have completed the required education to obtain a license. However, in the states in which naturopathy is not licensed, there is no required training for those who choose to call themselves naturopaths.

Thirty-three states and the District of Columbia license massage therapists, and the majority require passage of the National Certification Exam and graduation from an accredited program of 500 hours or more. The Commission of Massage Therapy Accreditation (COMTA) has established competencies for massage educational programs, although the majority of training programs are not yet COMTA accredited. However, “training, and licensure vary greatly from region to region, and there is currently a minimum of professional standardization” (Chrisman, 2001). In the states that lack licensure requirements, there are no educational requirements. In 5 states, licenses in homeopathy can be obtained by individuals with an MD, acupuncture is regulated in 33 states, and the Doctor of Oriental Medicine license is available in 3 states. In states with licensure requirements, certain requirements and standards must be met to obtain a license, although these requirements may vary greatly. In states that do not license these professions and, for the many CAM modalities that are not licensed at all, there are no educational requirements and, therefore, no standardized training for those in practice. Such a situation presents a major challenge to those interested in implementing new programs of education for CAM practitioners.

The committee, in responding to its charge to identify major scientific, policy, and practice issues related to CAM research and the translation of validated therapies into conventional practice, points out that the state of education and training for many CAM practices is a major issue. Addressing this issue in depth is beyond the charge of this committee; however, there are two areas where the committee focused its attention that are within its charge. First, it is often stated that CAM practitioners offer a patient-centered approach to care. As can be seen from the discussions throughout this report, the committee heartily supports the concept of patient-centered care and has endorsed the recommendations presented in Crossing the Quality Chasm (IOM, 2001) that health practitioners should engage in such care. Although a great deal of research has evaluated patient interactions with conventional medical providers, little research that has examined practitioner-patient interaction or the delivery of patient-centered care has been conducted for most CAM therapies, including the five therapies in which practitioners are licensed. Nor does the committee have information that the various educational programs for CAM practitioners teach a patient-centered approach to care. Given this lack of information, we cannot say with certainty that CAM practitioners know how to provide such care or, if they do know how, whether they actually do so. Therefore, the committee wishes to emphasize that CAM practitioners should be taught the principles and processes of patient-centered care, as should conventional medical practitioners.

The second area of education about which the committee has chosen to comment relates to research training. In its charge, the sponsor asked the committee to provide guidance on “the shortage of highly skilled practitioners who are able to participate in scientific inquiry that meets NIH guidelines, and who have access to institutions where such research is conducted” (committee statement of task). The discussion in the next section focuses on this issue.

Teaching Research

A major goal of research on CAM therapies is to produce reliable evidence of the safety, efficacy, and effectiveness of CAM approaches. At present, however, there is a dearth of qualified scientists to undertake the broad range of research that is needed to address the gaps in evidence on CAM approaches.

Two major potential sources of trained scientists exist: academic health centers and CAM institutions. Training in research was not a part of CAM clinical training, nor for the most part have careers in CAM been dependent on publishing research findings. CAM institutions focus primarily on training for practice, for which an important incentive on the part of the institution is financial; the institutions are dependent on tuition from students, and the students in turn are motivated to enroll so that they can eventually earn income as practitioners. CAM practitioners have very little incentive to become trained in research. Furthermore, very few CAM settings have the infrastructure to facilitate the development of research teams.

To ensure that research reflects as much as possible the actual ways in which CAM therapies are practiced, it is important to have CAM practitioners involved in such research. “Studies might provide more accurate and applicable information when professionals with a profound understanding of the therapies participate in the research design, ensuring that studies accurately evaluate the safety and efficacy of treatments without compromising the integrity of the medicine” (Shaw et al., 2003).

As discussed in previous chapters, additional research about CAM is needed to understand many important factors, for example, why and how people choose to use CAM, the extent to which various CAM modalities are effective, whether CAM treatments are cost-effective, the placebo effect, and much more. CAM practitioners are important to the development and implementation of these types of research. Furthermore, CAM practitioners have a responsibility to ensure that their practices are of benefit to their patients. Because ongoing evaluation and research foster improvements, the information that emerges from these research studies will be of great value to both CAM practitioners and those in conventional medicine who are engaged in attempting to provide the best care for their patients. In the area of chiropractic, for example, Flanagan and Giordano (2002) suggest, “Chiropractic institutions must embrace the initiative to train students to actively conduct research, provide incentives to train researchers to become chiropractors, and motivate practitioners in academically based joint efforts to contribute to strictly conducted outcomes studies.”

Flanagan and Giordano (2002) examined why progress in the training of chiropractic researchers has been slow, pointing out that there are few opportunities in chiropractic institutions for research faculty; of the $224 million total available for U.S. chiropractic colleges, most is used to “enhance and maintain student enrollment,” with only 2.5 percent allocated to research programs. Flanagan and Giordano argue however, that research should be given a higher priority; that it not only achieves outcomes-based results but also encourages faculty collaboration. They conclude by encouraging chiropractic institutions to train students in research, thereby creating “an environment that stimulates and supports research to fortify the integrity of the chiropractic profession, the communities it serves, and society at large.”

CAM practitioners not only must know how to conduct research but also must know how to write up the results. Jobst and Murphy (1999) write, “The willingness to share the expertise, to have one's ‘sacred cows’ examined for the greater good in order to better understand what helps heal is what is needed not only in CAM practices but also in orthodox medicine.”

Programs in CAM Research

Several efforts have begun to address the need to train CAM practitioners to participate in research. For example, Georgetown University has launched a science-based master's program in CAM in which graduates receive a master's in physiology. The program trains students to analyze current research critically using traditional methods of scientific inquiry, provides practice in designing research studies, and teaches students to identify areas requiring further research. In another effort, ten massage therapy schools have formed the Massage Therapy Research Consortium with the aim of enhancing each member school's research capacity and activity, as well as to advance massage therapy education and practice generally. The initial focus will be on education about research designs and methods (CHRF, 2004).

The University of Pennsylvania Health System has a 2-year program, based in the Center for Epidemiology and Biostatistics, that focuses on teaching CAM practitioners how to conduct research. The first year is devoted to learning research methodologies while the second year is spent applying the methodology. As of March 2004, five individuals were enrolled in the program: four CAM practitioners and one anesthesiologist interested in applying CAM in the management of arthritic pain (Fishman, 2004).

The Oregon Center for CAM (based at Kaiser Permanente's Center for Health Research) has begun a program aimed at training CAM practitioners to conduct and collaborate in research. The postdoctoral fellowship is open to graduates who hold a PhD (Doctor of Philosophy), MD (Doctor of Medicine), ND (Doctor of Naturopathy), DDS (Doctor of Dentistry), DO (Doctor of Osteopathy), or DC (Doctor of Chiropractic) degree. Acupuncturists, chiropractors, dental hygienists, massage therapists, naturopaths, nurses, osteopaths, physician's assistants, physicians, and dentists can apply for the part-time clinician fellowship. The program includes individual mentoring and training, group mentoring, a clinical research class, education on the development of a research proposal, and a journal club. Mentoring is a key component of the training with mentors and fellows matched on the basis of their research interests, backgrounds, and skills. Together, the mentors and fellows establish goals for the training, select projects, and outline how time will be distributed among selected projects, meetings and seminars, and additional activities. The clinical research component teaches classes that include such topics as grant writing, study administration, and writing for publication. The proposal development process

acts as a vehicle for instruction and practice in electronic literature searches articulating specific aims; matching research design to research questions; exploring research methodologies appropriate to CAM and how and when qualitative and quantitative techniques should be applied; selecting outcome measures, options for data analysis, and issues related to the protection of human participants in research studies.

(Shaw et al., 2003)

The Palmer Center for Chiropractic Research and the Division of Graduate Studies at the Palmer College of Chiropractic are collaborating with the School of Public Health at the University of Iowa to offer a 2-year curriculum in clinical research training to selected chiropractors. The goals of the program are to train chiropractors to become productive clinical investigators and to increase the chiropractic and CAM research workforce. The program consists of course work, mentoring, seminars, and workshops. Graduates of the program are expected to be able to

  • select and apply appropriate study design and statistics;
  • conduct clinical research according to professional and legal ethical standards;
  • lead and manage a productive career in clinical research;
  • acquire and maintain expertise in a research domain and communicate scientific knowledge through verbal presentations; and
  • write well-organized, logical journal publications, research proposals, and grant applications.

In addition to providing research training in CAM clinical educational institutions, another approach is to incorporate research training through collaborations with conventional medical research institutions. For example, the Research Collaborative between the New England School of Acupuncture (NESA) and Harvard University explores the efficacy and safety of acupuncture, while it also engages in academic and administrative mentoring programs to prepare NESA faculty and students to submit competitive NIH grant applications.

LESSONS FROM OTHER FIELDS

The development of a cadre of scientists trained to perform research on CAM therapies will occur only as part of the overall development of CAM science and education, especially in academic health centers, but also in CAM institutions. Two other fields have gone through processes that are relevant to the challenges faced by CAM in attempting to develop qualified researchers and a research infrastructure: geriatrics and HIV/AIDS. The experiences that practitioners in both of these fields underwent illustrate the importance of using multiple strategies to create an environment in which new science can flourish.

Geriatrics1

In the late 1960s, geriatricians were often thought of as “nursing home doctors.” Practitioners had low professional status and were economically marginal. In the 1970s U.S. geriatrics was at a crossroad; should it develop as a service discipline that was focused on long-term care and the disabled and dying, that was outside the academic mainstream, and that was based mainly in nursing homes; or should it develop along the lines of a respected, first-quality professional discipline in the classic academic model combining research, education and training, and innovative clinical care? The field moved in the latter direction with a number of milestones marking its progress.

Warshaw and Bragg (2003) describe a series of events in the history of geriatrics. In 1974 the National Institute on Aging (NIA) was established, and in 1976 the Veterans' Health Administration (VHA) initiated the Geriatric Research, Education and Clinical Care Centers to improve physician knowledge of aging and quality of care for veterans. Two years later the IOM published a report stating that geriatrics must become imbedded in medical education (IOM, 1978). During, that same year VHA began offering the first geriatrics fellowships.

In the early 1980s the first divisions of geriatrics were established at major academic health centers, including the University of California at Los Angeles and Washington, Duke, Cornell, Harvard, and Johns Hopkins Universities. In 1987 a second IOM report recommended the establishment of centers of excellence in geriatrics. Such centers create critical mass as well as the multidisciplinary expertise required to advance the scientific agenda. At the same time, foundation support for the development of curricula and partnerships in geriatrics became available. The Hartford Foundation, for example, contributed support that was critical to the establishment of partnerships within academic health centers (Warshaw and Bragg, 2003). This laid the foundation for the integration of geriatrics into the subspecialties of internal medicine, the development of geriatrics programs within surgical and related medical specialties, and the creation of analogous programs in geriatric nursing and social work. Today geriatrics is firmly established as a separate area of study in academic health centers. It is taught as part of the curricula of nearly all medical schools, and clinical training in geriatrics is required as part of residencies in internal medicine, family practice, obstetrics and gynecology, and psychiatry. Today there are approximately 100 fellowship training programs in geriatrics, the NIA annual budget is more than $1 billion, the field receives robust funding from industry, and collaborations exist between geriatrics and multiple disciplines (NIA, 2004).

A program developed to train geriatricians to conduct research provides some lessons about the development of programs for CAM practitioners. The Summer Research Institute developed at the University of California in San Diego under an R-25 grant from the National Institute of Mental Health (NIMH) is an annual week-long training program for 25 participants with regular follow-up after the program. Its goals are to increase knowledge of what research involves and increase motivation for a research career; provide information regarding issues and methods in research; shorten the time interval between the end of training and receipt of the first external grant; and foster relationships with established investigators and peers. Faculty include individuals who have been successful at obtaining research funding as well as those who are able to teach scientific ethics and integrity. Core sessions provide education about

  • scientific integrity;
  • preparation of scientific autobiographies;
  • career guidance;
  • preparation of grants, papers, and presentations;
  • recruitment and retention of research subjects;
  • research administration;
  • balancing life and work; and
  • individual mentoring.

In terms of achievement, of the 123 individuals who have attended one of these institutes, 90 percent have “presented and written publishable papers within a year of attendance, and over 50 percent have received grant funding within 18 months” of completing the program (Halpain et al., 2001).

HIV/AIDS2

In the early 1980s, HIV/AIDS was a newly discovered disease without a ready-made research workforce to investigate it. Over the subsequent 10 to 15 years, the field attracted many seasoned scientists and trained new ones, with the result that, today, a well-developed research workforce operates at all levels of HIV/AIDS-related science. The development of scientists trained to conduct behavioral research in HIV/AIDS provides an excellent case illustration with many relevant applications to the development of CAM research.

The development of behavioral research in HIV/AIDS was spurred by scientists who were present when AIDS first emerged in the United States. In 1983 NIMH received four investigator-initiated grant applications. Support was provided from the director's supplemental funds. The NIH Office of AIDS Research was established in 1988, accompanied in the same year by the establishment of the Office of AIDS Research at the NIMH. The NIMH program used a number of strategies to jump start research including announcements for requests for applications, program announcements for secondary data analysis, supplemental funding to existing R01 grants, supplemental funding from nongrant organizations, community participation, aggressive technical assistance and grant monitoring, and the creation of consortia of investigators that brought together investigators to address novel ideas. Of particular interest was the involvement of NIMH program staff in the grant development process. The staff was encouraged to work with investigators, especially junior investigators, to help them develop strong proposals. The NIMH program also devoted extensive resources to training. It established institutional training grants, supplements to training grants, postdoctoral and predoctoral fellowships, minority and disability supplements, and career development awards.

Of particular interest is a program that was developed to train behavioral and social scientists to conduct HIV/AIDS behavioral research with minority populations. The Collaborative HIV Prevention Research in Minority Communities Program (Marin and Diaz, 2002) is a comprehensive intensive program that provides training, research collaboration, and technical assistance over a 2-year period. The 27-month program includes funding for small grants, a structured summer program to which the participants return for three summers, individualized long-term research collaboration in which program faculty serve as mentors throughout the year, and access to relevant scientific expertise. Although such programs require a large investment of resources, the participants emerge with preliminary data and fundable research proposals. This program may be a model that can be used to train CAM practitioners to become rigorous researchers.

Many CAM institutions do not at present have the infrastructure or institutional culture for research, nor do they have the financial resources to develop them. Strategic partnerships with NIH and academic health sciences universities would help foster this development. NCCAM has funded such partnerships (e.g., NESA and Harvard University Research Collaborative). It will be important to be able to define characteristics of the CAM institution, the traditional academic institution, and the relationship between them that will predict the successful development of research capabilities at the CAM institutions.

It is important to increase the numbers of trained researchers who come from the CAM fields of practice in order to advance knowledge about CAM. Well trained CAM researchers would be in a position to lead investigations into research in their own domains and participate in the design and conduct of other research on these therapies. Increasing the number of such researchers, however, depends on the availability and implementation of research training.

PRACTICE GUIDELINES

The variations in the kinds of education and training for CAM practitioners, particularly unlicensed practitioners, were discussed above. Variation in education, however, leads to variations in clinical practice. Many CAM practitioners argue that their therapies are individualized to meet the specific needs of each patient and that variation is good. Conventional medical practitioners also tailor therapies to individual patients, and when practice guidelines were first proposed, many were concerned about the negative effects of those guidelines on “clinical autonomy, health care costs, and satisfaction with clinical practice” (Tunis et al., 1994). Indeed, both conventional medical and CAM practitioners would argue strenuously against “cookbook” clinical practice.

Variation makes it difficult to conduct research on the efficacy or effectiveness of certain therapies because no practice guidelines have been agreed upon. However, CAM practitioners could develop their own practice guidelines. Such guidelines would help overcome some of the difficulties of inappropriate practice variation in research. Practice guidelines are “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances” (IOM, 1990). Ideally, good practice guidelines have eight attributes, although, as the IOM report recognized, it is not anticipated that practice guidelines will score well on each of these attributes. Rather, they are something to strive for. Guidelines should

  • be valid; when followed they result in anticipated health outcomes.
  • be reliable and reproducible; any group of experts would develop similar guidelines given the same evidence and methods.
  • have clinical applicability; they should be inclusive of appropriately defined patients as permitted by scientific and clinical evidence and expert judgement.
  • have clinical flexibility; the known or expected exceptions should be identified.
  • have clarity; they should be easy to follow and should use clear, unambiguous language.
  • be developed by using a multidisciplinary process; all key groups affected should participate.
  • have scheduled reviews; times for review and revision should be determined.
  • have documentation of the process, participants, evidence, and assumptions used for guideline development (IOM, 1990).

Two major approaches are used to develop such guidelines. The first is an evidence-based approach. In conventional medicine evidence consists of that obtained by Western-scientific type evaluations. Mills et al. (2002) proposed that evidence-based CAM (EBCAM) be taught to CAM practitioners and outlined the implications of such education (Table 8-3). They argue that, even though EBCAM is viewed negatively by many in the CAM community, in reality it is not incompatible with the principles of holism and clinical autonomy. Research results are only one factor that CAM practitioners consider when they make a clinical decision. Other factors include clinical judgment and patient values. “The essence of the EBCAM process is the use of data collected on groups of patients to assist clinical judgment. However, ultimately these data need to be transferred to the individual recognizing that it is likely the patient being examined will differ from the average patient in the study” (Wilson and Mills, 2002). What is needed is a blending of research findings with the values of patients and CAM providers to improve how clinical decisions are made (Mills et al., 2002).

TABLE 8-3. Implications of Introducing Evidence-Based Medicine Strategies into CAM Curricula.

TABLE 8-3

Implications of Introducing Evidence-Based Medicine Strategies into CAM Curricula.

For CAM practices for which standard Western scientific research is lacking, experiential evidence and traditional healing manuals might be used. This could be combined with the second approach discussed in the IOM report on practice guidelines; the use of professional judgment. This second approach is used in areas in which the science is weak or nonexistent (IOM, 1992).

A key element of practice guidelines is that their development be undertaken by those who will be affected by the guidelines as recommended in the IOM report (IOM, 1992). This includes practitioners, patients, and consumers. Professional societies are also frequently involved in sponsoring the development of practice guidelines.

CONCLUSIONS AND RECOMMENDATIONS

Education about CAM is needed for both conventional medical practitioners and CAM practitioners. For those in conventional practice, it is important to learn about CAM to appropriately interact with and advise patients in a manner that contributes to high-quality, comprehensive care. There are no guidelines on what should be taught, and great heterogeneity in the content and methods in use exist. Suggestions on what should be taught frequently emphasize critical thinking and the evaluation of therapies, as well as an understanding of different belief systems. Didactic approaches to teaching include electives, required courses, or the integration of CAM content into existing courses throughout all years of training. Some programs include experiential learning, fellowship, and residency programs. Although the individual content and organization of an educational program on CAM vary from institution to institution on the basis of the goals and objectives of each program, the committee believes that it is essential to provide health professionals of today with information sufficient to enable them to competently advise their patients. Therefore, the committee recommends that health profession schools (e.g., schools of medicine, nursing, pharmacy, and allied health) incorporate sufficient information about CAM into the standard curriculum at the undergraduate, graduate, and postgraduate levels to enable licensed professionals to competently advise their patients about CAM. As such programs are introduced, it will be important to subject them to the same evaluation and scrutiny that are applied to curricula on other topics.

Many issues related to the training of the CAM practitioners are beyond the scope of this committee. It is clear, however, that CAM practitioners who are well trained in the conduct of research are needed. Such individuals are important to the design and conduct of studies that accurately reflect how CAM therapies are practiced. Some programs aimed at preparing CAM practitioners trained in research have been implemented. These tend to be programs rather than individual courses, and all include curriculum on research design and methods. Lessons can also be learned from other fields, for example, the fields of geriatrics and of HIV/AIDS research. The Summer Research Institute developed to train researchers in geriatrics provides some useful ideas for enlarging the number of researchers trained in CAM research. Another model that could prove useful is the Collaborative HIV Prevention Research in Minority Communities Program, a 27-month program that includes funding for small grants, a structured summer program to which the participants return for three summers, individualized long-term research collaboration with program faculty serving as mentors throughout the year, and access to relevant scientific expertise.

Many CAM institutions do not have the infrastructure or institutional culture for research, nor do they have the financial resources to develop them. Strategic partnerships with NIH and academic health sciences universities would help foster this development. NCCAM has funded such partnerships. It will be important to be able to define the characteristics of the CAM institution, the traditional academic institution, and the relationship between them that predict the successful development of research activities at the CAM institutions. Furthermore, some CAM modalities are not taught within an educational infrastructure such as that provided by schools of chiropractic medicine, naturopathy, or massage therapy. For practitioners of modalities without such an educational infrastructure it will be more difficult to develop the necessary research expertise.

The committee believes that despite the difficulties, it is of the highest importance to develop and implement research training for CAM practitioners. Therefore, the committee recommends that federal and state agencies, and private and corporate foundations, alone and in partnership, create models in research training for CAM practitioners.

Furthermore, both research and quality would be fostered by the development of practice guidelines for CAM therapies. Practice guidelines are “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances” (IOM, 1992). Guidelines provide an important tool that the members of a discipline can use to assess the quality of care they provide. They are developed by using both evidence-based approaches and professional judgment. Key to guideline development is the participation of those who will be affected by the guidelines. This means that CAM practitioners, possibly through their own professional organizations, would develop guidelines for their own therapies. Such guideline development requires knowledge about evidence-based decision making and the appropriate use of the therapies under consideration. The committee recommends that the national professional organizations for all CAM disciplines ensure the presence of training standards and develop practice guidelines. Health care professional licensing boards and accrediting and certifying agencies (for both CAM and conventional medicine) should set competency standards in the appropriate use of both conventional medicine and CAM therapies, consistent with practitioners' scope of practice and standards of referral across health professions.

Both conventional medicine practitioners and CAM practitioners have educational challenges ahead. However, meeting those challenges will contribute to the knowledge base and therefore the ability to provide comprehensive care that uses the best scientific evidence on benefits and harm available, encourages a focus on healing, recognizes the importance of compassion and caring, emphasizes the centrality of relationship-based care, encourages patients to share in decision making about therapeutic options, and promotes choices in care that can include CAM therapies where appropriate.

The next chapter examines the area of dietary supplements.

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Footnotes

1

The material in this section is taken, in part, from a presentation to the committee by William R. Hazzard, MD, professor of medicine at the University of Washington and director of geriatrics and extended care at the VA Puget Sound Health Care System.

2

The material in this section is taken from a presentation to the committee by Willo Pequegnat, MD, associate director for AIDS and mental health programs, National Institute of Mental Health.

Copyright © 2005, National Academy of Sciences.
Bookshelf ID: NBK83809

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