Incorporating a Web-based, Integrative Medicine Curriculum into 8 Family Medicine Residencies: Keys to Success Victoria Maizes, M.D., Victor Sierpina, M.D., John Woytowicz, M.D., Selma Sroka, M.D., Sally Dodds, Ph.D., & Patricia Lebensohn, M.D.

Presentation Objectives The objectives of this presentation are: ▫Recognize the steps in creating competency-based education including the evaluation methodology. ▫Understand program strategies used in incorporating a new curriculum into existing residency training. ▫Review key outcomes of courses completed and change in IMR medical knowledge. ▫Review individual program successes and challenges in implementation methodology.

Integrative Medicine in Residency (IMR) is… Competency-based, online, 200-hour, curriculum. In-depth training in Integrative Medicine. Incorporated through all 3 years of Family Medicine residency. Piloted at 8 residencies nationwide. Seamless, online evaluation of the curriculum and the residents. Responds to ACGME competency requirements. Evaluation developed simultaneously with the curriculum.

University of Arizona University of Texas Medical Branch Hennepin County Carolinas Medical Center Beth Israel Maine-Dartmouth Maine Medical Center University of Connecticut IMR Program Locations Moses H. Cone Alaska Family Medicine Univ. of Minn A. Einstein Montefiore Control sites

IMR Curriculum Units

Introduction to Integrative Medicine Prevention and Wellness: U.S. Preventive Health Services Nutrition and Diet Supplements for Prevention Physical Activity Sleep Stress and Mind-Body Medicine Spirituality Clinical Integration Tools in Integrative Medicine: Integrative Medicine Intake and Care Plan Botanicals Mind-Body Medicine Manual Medicine Introduction to Energy Medicine and Whole Systems Practice Management Motivational Interviewing for Behavioral Change Acute Care: Acute Back Pain, Urinary Tract Infection, Gastroenteritis, Otitis Media, Vaginitis, Atypical Chest Pain, Upper Respiratory Infection Introduction to Integrative Medicine Prevention and Wellness: U.S. Preventive Health Services Nutrition and Diet Supplements for Prevention Physical Activity Sleep Stress and Mind-Body Medicine Spirituality Clinical Integration Tools in Integrative Medicine: Integrative Medicine Intake and Care Plan Botanicals Mind-Body Medicine Manual Medicine Introduction to Energy Medicine and Whole Systems Practice Management Motivational Interviewing for Behavioral Change Acute Care: Acute Back Pain, Urinary Tract Infection, Gastroenteritis, Otitis Media, Vaginitis, Atypical Chest Pain, Upper Respiratory Infection Pediatric Topics: ADD/ADHD Chronic Pain Syndrome Asthma and Allergies Women’s Health Topics: PMS/PMDD Dysmenorrhea Menopause Fibromyalgia Osteoporosis Depression Eating Disorders Pregnancy and Lactation Chronic Illness: Cardiovascular Disease Type II Diabetes Osteoarthritis Rheumatoid Arthritis Obesity Irritable Bowel Syndrome Chronic Back Pain Special Topics: HIV/AIDS Cancer Survivorship Environmental Medicine Pediatric Topics: ADD/ADHD Chronic Pain Syndrome Asthma and Allergies Women’s Health Topics: PMS/PMDD Dysmenorrhea Menopause Fibromyalgia Osteoporosis Depression Eating Disorders Pregnancy and Lactation Chronic Illness: Cardiovascular Disease Type II Diabetes Osteoarthritis Rheumatoid Arthritis Obesity Irritable Bowel Syndrome Chronic Back Pain Special Topics: HIV/AIDS Cancer Survivorship Environmental Medicine Units and Courses

IMR: Educational Methods  Needs assessment informed curriculum design.  Web-based curriculum written and edited by Integrative Medicine educators.  Competencies aligned with the ACGME Outcomes Project.  Flexible modular format to meet the needs of residency schedules.  Case-based, interactive learning and streaming video.  Experiential exercises and process-oriented group activities at the residency sites.  A community of learners through online dialogues with faculty and peers.  Emphasis on teaching and promoting physician well- being and self-care.

IMR User Interface Online portfolios Flexible modular format Resources and Links Direct Observation Checklists Reflections

What is Evaluated in the IMR? Curriculum: ▫Residents evaluate each course after completion Residents’ competencies: ▫Medical Knowledge test ▫Self Assessment ▫Direct Observation Checklist ▫Reflections Residents’ wellness & well-being: ▫Behavioral assessments Residency recruitment: ▫Match results and post match survey

As of March 19, 2010 Yr 01 Course Completions Classes of 2011 and 2012

As of March 19, 2010 Yr 02 Course Completions Class of 2011

Clinical Utility of the Course? Year 01 Content *Currently, indicators are available for 4 courses for the 2012 class.

Meet Learning Objectives?Clinical Utility? Year 02 Course Evaluations Courses currently at 50% threshold

Smooth Online technology?

Medical Knowledge Test Mean percent correct at baseline – All groups ns

Medical Knowledge Test Sub group differences at baseline – Class of 2011 Sex Medical School Status

Medical Knowledge Test Pre-/Post Test Class of 2011 – Yr. 01

Post Match 1 Match Results 2011, 2012, 2013

Post Match 2 IM/CAM Medical School Courses &Personal Use Controls rated higher than 2012 group on all questions. * 2011 more required IM/CAM courses in medical school than 2012 (p<.001). * 2011 more electives in medical school than 2012 (p<.001). * Controls more electives than 2012 (p=.012). * 2011 more personal IM/CAM use than the 2012 group (p=.014). 2011(n=57) 2012 (n=43) Control(n=30)

Post Match 3 Interest in Learning IM in Residency High interest in both the 2011 and 2012 groups. But, over half of the controls also had high interest. * 2011 group had a higher interest than controls (p=.002). 2011(n=57) 2012 (n=43) Control(n=30)

Post Match 4 Importance of the IMR in Ranking Decision Very important/Important: 2011 – 53% 2012 – 37% Notes: 1. Likert scale revised to 5 points and accounts for differences in scores totals >100%– rounding error. 2011(n=57) 2012 (n=43)

Post Match 5 Interest in Applying IM in Practice High to moderate interest in both the 2011 and 2012 groups. Controls also had high to moderate interest. * 2011 group had higher interest in applying IM in practice than controls (p=.001). Notes: totals more than 100%– rounding error 2011(n=57) 2012 (n=43) Control (n=30)

I mplementation Strategies Individual activities: Free blocks of time longitudinally Use concentrated time in certain rotations (orientation, community medicine, integrative medicine, nursery). Do content matched with rotations (e.g., outpatient pediatrics, maternal child health, GYN, EM) Group activities: Wellness and self care Videos Motivational interviewing Mind-Body skills training Integration with behavioral health program Field trips Yoga, tai chi OMT skills Nutrition lecture series Integrative approach to lecture topics

Implementation Challenges Finding the time in the curriculum. Motivating some residents to keep on track and progress through the curriculum. Getting faculty interested in participating in the curriculum. Incorporating an Integrative Medicine approach into busy outpatient care sessions.

Implementation Successes Most residents are progressing well through the curriculum. Evaluations are very encouraging. One sites from the 2011 class is requesting continued access to the curriculum after graduation. The presence of the IMR attracts competitive residents to the pilot sites. Residents’ medical knowledge has increased from Yr. 01 to Yr. o2. Unknown: Residents’ well-being Patient centeredness Patient outcomes Practice patterns after graduation

Next Steps Complete the Yr. 03 content Analyze Behavioral Assessments/residents’ well-being and compare with control groups Expand to other programs 5 early adopters in 2010 Medical Center of Central Georgia, Macon, GA Tufts University Family Medicine, Malden, MA Aurora Family Medicine Residency Program, Milwaukee, WI; Research Family Medicine, Kansas City, MO; Internal Medicine Residency University of New Mexico, Albuquerque NM. Build a stand alone course on Prevention and Wellness for residents and medical students

Discussion Acknowledgements University of ArizonaPilot Sites Emily SherbrookeMary Guerrera, M.D. Paula CookBen Kligler, M.D., MPH Rhonda HallquistCraig Schneider, M.D. Tieraona Low Dog, M.D.Raymond Teets, M.D. Dael Waxman, M.D.

Teaching Strategies SiteCourseTeaching Strategy Examples U of APhysical Activity Supplements Yoga class Visit to health food store w/ cases & budget Maine MCSupplements Nutrition Visit to traditional herbalist store Trip to chicken processing plant U ConnNutritionLecture with sampling of various foods Beth IsraelNutritionEvening dinner discussion HennepinStress and M-BExperience in PMR, hypnosis, breath work CarolinasPhysical Activity Stress and M-B Ropes course w/ faculty during orientation Mindfulness meditation sessions U TexasStress and M-BLecture and acupuncture experience Maine GenClinical IntegrationPatient joins the IMR case staffing