1. An Experiential, Learner-Driven Complementary & Alternative Medicine Curriculum in a Family Medicine Clerkship An Experiential, Learner-Driven Complementary & Alternative Medicine Curriculum in a Family Medicine Clerkship Richard Glickman-Simon, MD Department of Public Health & Family Medicine Tufts University School of Medicine richard.glickman-simon@tufts.edu wayne.altman@tufts.edu Wayne Altman, MD

2. A Definition Complementary and alternative medical therapies are medical “interventions neither taught widely in U.S. medical schools nor generally available in U.S. hospitals.” Eisenberg DM. Davis RB. Ettner SL. Appel S. Wilkey S. Van Rompay M. Kessler RC. Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. JAMA. 280(18):1569-75, 1998 Nov 11.

3. LCME Annual Medical School Questionnaire 126 US Schools, 2002-03 Barzansky B. Etzel SI. Educational programs in US medical schools, 2002-2003. JAMA. 290(9):1190-6, 2003 Sep 3.

4. Another Definition “A broad domain of healing resources that encompasses all health systems, modalities, and practices and their accompanying theories and beliefs, other than those intrinsic to the politically dominant health system of a particular society or culture in a given historical period. Boundaries within CAM and between the CAM domain and that of the dominant system are not always sharp or fixed.” The Cochrane Collaboration

5. What constitutes CAM? Biologic Nutritional Medicine Botanicals Dietary Supplements Mind-Body Meditation Yoga Prayer Energetic Therapeutic touch Reiki EM Fields Manipulative Chiropractic Osteopathic Massage Acupuncture Systems Traditional Chinese Medicine Ayurveda Homeopathy Naturopathy Christian Science

6. What constitutes CAM? Self-Administered Deep breathing exercises Diet-based therapies Guided imagery Homeopathic treatment Meditation Megavitamin therapy Non-vitamin, non-mineral dietary supplements (eg, herbs) Prayer Progressive relaxation Qi gong Tai Chi Yoga Practitioner-Based Acupuncture Ayurveda Biofeedback Chelation therapy Chiropractic Christian Science Energy healing Folk medicine Hypnosis Herbal medicine Homeopathy Massage Naturopathy Reiki

7. CAM Use by U.S. Adults 2002 CDC: National Health Interview Survey 2002

8. 10 Most Common CAM Therapies CDC: National Health Interview Survey 2002

9. Conditions for Which CAM is Most Frequently Used CDC: National Health Interview Survey 2002

10. CAM in Medical Curricula Purpose Keep patients safe Improve patient-physician communication Produce culturally competent physicians Enlighten physicians regarding the nature of evidence and uncertainty Instill in physicians an attitude of personal wellness and self-care Improve health outcomes CAM’s Effect on Health Outcomes Safe and effective interventions Mitigated stress response Potent placebo

11. CAM in Medical Curricula Objectives Broad coverage of CAM therapies and systems Focused coverage of demographic, safety and/or regulatory issues Model to demonstrate principles relevant to allopathic medicine Practical aspects pertaining to the integration of allopathic with non-allopathic care Clinical training in the practice of selected CAM therapies

12. CAM in Medical Curricula Methods Required vs. elective Standalone vs. integrated Clinical vs. longitudinal Allopathic vs. non-allopathic instructors Emphasize knowledge, attitudes or skills Teaching Formats Lecture Guest seminars Group discussion Case-based (e.g., PBL) Web-based Standardized patients Workshops / demonstrations Practice visitation Practical training

13. Characteristic of CAM Courses Taught in Selected U.S. Medical Schools, 2000 % Respondents Type of course Required Elective 30.1 75.3 Academic year First Second Third Fourth 42.5 34.2 30.1 47.9 Total hours < 20 20 – 60 61 – 100 > 100 Variable/unspecified 52.1 23.3 8.2 9.6 6.8 Brokaw JJ. Tunnicliff G. Raess BU. Saxon DW. The teaching of complementary and alternative medicine in U.S. medical schools: a survey of course directors. Academic Medicine. 77(9):876-81, 2002 Sep.

14. Sponsoring Unit of CAM Courses % Respondents Family Medicine Internal medicine Medical humanities/sociology Psychiatry Integrative medicine Campus ministry or dean’s office Pediatrics Medical education Pharmacology Pathology Biochemistry Miscellaneous/unspecified 33.7 14.9 10.0 7.5 6.3 3.7 2.5 1.4 13.7 Brokaw JJ. Tunnicliff G. Raess BU. Saxon DW. The teaching of complementary and alternative medicine in U.S. medical schools: a survey of course directors. Academic Medicine. 77(9):876-81, 2002 Sep.

15. Topics and Contact Hours % Teaching Topic TopicMedian Hours >75%Acupuncture 2.0 51 – 75%Herbal medicine Meditation & relaxation Spirituality/faith/prayer Chiropractic Homeopathy Nutrition & special diets 2.2 26 – 50%Ethnomedicine Massage therapy Hypnosis Therapeutic touch Guided imagery Dietary supplements Naturopathy Biofeedback 1.8 10 – 25%Aromatherapy Energy medicine Music Therapy Reflexology 1.8 Brokaw JJ. Tunnicliff G. Raess BU. Saxon DW. The teaching of complementary and alternative medicine in U.S. medical schools: a survey of course directors. Academic Medicine. 77(9):876-81, 2002 Sep.

16. Components of Tufts CAM Curriculum Case Discussion Web-based evidence review CAM practice visits Debriefing and case follow-up Yoga session

17. Case Paul Spencer is a 48 year-old auto mechanic who comes to you concerned about pain in his lower back for the past six months. When the pain first started, he was seeing another physician at a neighborhood health clinic who took and x-ray and referred him to a physical therapist. Work has become increasingly difficult on account of the persistent pain, and lately, he has been calling in sick at least once a week. The owner of the shop has taken notice and he's worried about losing his job. He's reluctant to consider surgery and he has no disability insurance.

18. Web-Based Evidence Review P.O.E.M. Project Tufts University Science Knowledgebase http://tusk.tufts.edu

19. Practice Visits Massage Therapy Acupuncture Chiropractic Tai Chi

20. Debriefing and Case Follow-up Issues Raised Contrast between allopathic and non- allopathic practices Standards of evidence Risk : benefit analyses Costs and coverage Engendering a placebo response

22. When should a conventional physician recommend alternative interventions? When it is safe When there’s no interference When follow-up is assured When there’s no diagnosis When the patient is paying When the mechanism of action is plausible? When there’s evidence for its effectiveness? When the patient expects it to work?

23. Future Plans Develop more structured objectives for CAM practice visits Follow-up on initial effort to evaluate effect of the curriculum on student attitudes about CAM and its allopathic integration Create or adopt a mechanism to evaluate student knowledge and skills in CAM Integrate CAM content over the four-year TUSM curriculum