Evidence-Based Medicine and the Chinese Medicine Profession An Exploration of Attitudes and Beliefs in Relation to Education and Cultural Change Belinda Anderson, PhD, LAc Academic Dean, Pacific College of Oriental Medicine (New York) Associate Professor, Albert Einstein College of Medicine Acupuncturist and Chinese Herbalist, New York University Fertility Center

Content Brief history of how PCOM-NY got involved with research Current externally funded research projects NIH funded 5-year Evidence Informed Practice research project Pilot pre-grant data Qualitative exploration of attitudes, beliefs and perspectives Scientific worldview differences between MD and PCOM students Conclusions and lessons learned

Brief History My research background/history Partnering with Einstein The NESA/Harvard NIH grant Partnering with Einstein Interprofessional student exchange program Faculty appointment 3 externally funded research grants

Current Research Projects NIH National Center for Complementary and Integrated Health K07 Career development award Evidence Informed Practice: Faculty and Curriculum Development 2013 – 2018 Patient Centered Outcomes Research Institute (PCORI) Acupuncture clinical trial 2015 - 2018 Health Resources and Services Administration (HRSA) Residency training program in wellness and prevention 2015 – 2018 Council of Colleges for Acupuncture and Oriental Medicine Investigating the scientific worldview differences between MD and PCOM students 2016 - 2017

NIH EIP Project

Components EIP skills/knowledge Students Developed a Foundations of EIP (FEIP) course – in all CM programs Pre and post tested self-reported skills/knowledge and importance Faculty Online EIP modules – University of Minnesota FEIP course in doctoral upgrade program Incorporating EIP into 70% of didactic entry-level CM curriculum Incorporating EIP into 100% of clinical entry-level CM curriculum Attitudes/beliefs/perspectives Pre-grant pilot data Qualitative study

NIH EIP Project – Pilot Data Surveys undertaken to provide data for the NIH proposal Exploring faculty and student’s Research skills and usage Support for research Attitudes, beliefs and perspectives about evidence-based medicine

Pilot Data Survey Faculty Students # Close-ended Qs* 14 18 # Open-ended Qs 1 Response Rate 89% (102/115) 42% (176/420) Prior Research Ed. 51% 40% Prior Res. Ed. Grad Level 41% 34% * Close-ended questions with 5-point Likert answers (Strongly agree; Agree; Neutral; Disagree; Strongly disagree). Results expressed as %Agree + Strongly agree

Outcome of Surveys# (% strongly agree + agree) Faculty Students Research Literacy – can find/evaluate 75 85* Supportive of research 88 - Interest in participating in research & EIP Training 73 EIP is of value to complementary & integrative medicine 81 76 *4th year students who had taken the introductory research course # Anderson et al. 2014. JACM 9:705; Anderson et al. 2016. Explore 12:366

Outcomes of Student Survey (% strongly agree + agree) Research Value 1st year 2nd year 3rd year 4th year Trend Outside the profession* 83 85 82 80 NS Compatibility of science & CM 63 47 50 31 P<0.01 Desire for further research training - 33 * Referral, insurance coverage, public perception

Similar Survey at NESA and OCOM (Wayne et al. 2010 Similar Survey at NESA and OCOM (Wayne et al. 2010. Explore 6:22) (% strongly agree + agree) Year 1 Year 2 Year 3 Trend Research value outside the profession 92 85 NS Research learning & participation 76 67 37 p<0.0008 Research value to improving clinical practice 87 45 p<0.005

Challenges Going in Resistance – themes from open-ended survey questions Incompatible paradigms Cooptation Relevancy to CM practice Cultural issues These issues were not highlighted by the faculty needs analysis using the instrument developed at Northwestern Health Sciences University Suspected unique challenges within CM profession

Qualitative study

Qualitative Study First cohort taking Fundamentals of Evidence Informed Practice as part of the doctoral upgrade program (DACM) Average years in practice 11.5 Analysis of online forums Based on Kaptchuk and Miller (2005). What is the most ethical model for the relationship between mainstream and alternative medicine: opposition, integration or pluralism? Academic Medicine. 2005, 80:286-290 They were asked to discuss the most ethical model for the relationship between mainstream and alternative medicine 31 of 33 students participated There were 33 initial posts (average 428 words/post), 127 response posts (average of four responses/initial post, with average length of response of 108 words).

Opposition/Integration/Pluralism (Kaptchuk & Miller 2005) Opposition - rejection of alternative medicine by conventional medicine Integration - amalgamating conventional and alternative therapies together in a holistic approach to the treatment of disease and promotion of wellness Pluralism - conventional and alternative therapies used together, but where cooperation, research, and open communication and respect between practitioners preserves the integrity of each of the treatment systems

Major Themes “Western based science looks at the world by tearing it up into very small pieces that can be analyzed.  By doing this to Eastern medicine, meaning and understanding are often lost.  Western medicine is interested in coming up with explanations for things, but we don’t always have quick explanations for how treatments work and therefore they become easily dismissed as invalid“ “The limitations of homogenizing two incongruous perspectives do a disservice to both. Interpreting a completely different system using a singular language is at best incoherent, and at worst, ineffective or harmful”. “It seems that education is key.  In order for there to be respect and referrals among different modalities, we need to understand what each modality does, and where its strengths and limitations lie.  All practitioners need to know when to refer out, and have an idea of where to refer” “The goal above all else is that the patient gets the best care” “Western Medicine is in charge of our destiny, and that is due to their social, economic and political influences” “I choose pluralism as our best ethical option” Major Themes Total # comments Total # & % of students that mentioned Preference for the pluralistic model 23 21 (68%) Opposition to integrative model 21 15 (48%) Importance of patient centeredness 18 17 (55%) Power imbalance &co-option issues 12 (39%) Imp of interprofessional education 13 10 (32%) Issues – research methodology & paradigms 10 7 (23%)

“this pluralistic streak in our own medicine has been integral to its continued evolution” “heralded in the West is the newest technology or drug, while heralded in the East is a lifetime of experience treating the human mechanism” “Creating an environment where the patients ability to be part of the game – and accommodate them when they are sub optimally resourced – is something our medical practices and institutions should endeavor to be nimble and responsive to without judgement, agenda or manipulation”. “If I had to choose, I would choose pluralism, but this choice is only chosen, as the least damaging to the integrity of our medicine” Minor Themes “Most of us had no idea about this term in our medical system prior to this class. We were all stuck on integration” “I do agree that opposition (at least ongoing opposition) is unethical and unreasonable as a strategy for functional relationship” Minor Theme Total # of comments Total # & % of students that mentioned Pluralism requires patients be able to advocate for themselves 6 4 (13% Prior education focused on integrative model 5 5 (16%) Against opposition model Pluralism maintains the integrity of CM 3 3 (10%) Importance of thousands of years of anecdotal evidence 2 (6%) Pluralism is also in CM

Scientific Worldviews

Survey Instrument Validated - Thinking about Science Survey Instrument – Cobern 2000 SLCSP 151. Kalamazoo, MI: Scientific Literacy and Cultural Studies Project  Designed to measure differences in scientific worldviews - socio-cultural resistance to, and support for, science The instrument consists of 60 questions with 5-point likert scale answers Categories of Qs - epistemology; science and economy; science and the environment; public policy and science; science and public health; science, religion and morality; science, emotions and aesthetics; science, race and gender; and science for all

Research Questions Do MD and CM students have different scientific worldviews? Do students who chose, or not, to participate in the interprofessional exchange program have different scientific worldviews? Does an inter-professional student education exchange program change their scientific worldviews?

Outcomes Q Category # Qs statistically different # agree/disagree Public policy 4 Public health Epistemology 3 Emotion & Aesthetics 1 Economy 2 Race & gender Science for all Environment/Resource Religion & morality Response rates – Einstein (122/170 = 72%; PCOM 48/107 = 45%)

Questions where Einstein & PCOM students were on opposite sides of neutral (3)* Q Category Question Einstein* PCOM* P Value Public health 8. Scientific knowledge is the single most important factor in the improvement of medicine and public health. 3.26 2.6 0.002 Race and gender 53. The scientific community is mostly dominated by white men and is often unfriendly to minority people. 3.31 2.88 0.02 Epistemology 60. Scientific knowledge is the truest form of knowledge. 3.32 2.67 0.001 33. The methods of science are the most reliable source of true, factual knowledge. 3.66 2.81 <0.0001 23. The scientific community is mostly dominated by men and is often unfriendly to women. 3.35 2.92 0.01 Economy 42. Science is our best source of useful knowledge. 3.69 2.79 34. Science is the best source of reliable knowledge. 3.75 2.90 *Means of Likert responses: Strongly agree = 5; Agree = 4; Neutral = 3; Disagree = 2; Strongly disagree = 1)

Conclusions & Lessons Learned

Conclusions and lessons learned CM students, faculty and practitioners: Are not anti science Understand and support the role of research in legitimizing CM But are concerned about: Autonomy and continued authentic practice of CM Cooptation Inappropriate research methodology being used for CM Keeping the patient at the center The need for interprofessional education to engender respect and understanding

Acknowledgments Research mentors Research Colleagues Drs. Ben Kligler, Paul Marantz at Einstein Dr. Roni Evans, University of Minesotta Dr. Corbin Campbell, Teachers College Columbia University Research Colleagues Drs. Diane McKee, Arya Nielsen, Claudia Citkovitz, Funding bodies: NIH, PCORI, HRSA, CCAOM Institutional support: PCOM, Einstein, Teachers College Columbia University

Thank you Belinda (Beau) Anderson Pacific College of Oriental Medicine 110 William St, 19th floor New York, NY 10038 212 982 3456 x216 banderson@pacificcollege.edu