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Why Integrative Medicine is Essential for Medical Education

Why Integrative Medicine is Essential for Medical Education. Aviad Haramati, PhD Professor of Physiology & Biophysics and Medicine Georgetown University School of Medicine Washington, DC USA Dir. Academic Programs, Institute for Integrative Health Baltimore, MD, USA.

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Why Integrative Medicine is Essential for Medical Education

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  1. Why Integrative Medicine is Essential for Medical Education Aviad Haramati, PhD Professor of Physiology & Biophysics and Medicine Georgetown University School of Medicine Washington, DC USA Dir. Academic Programs, Institute for Integrative Health Baltimore, MD, USA NVMO – Dutch Association on Medical Education Egmond Ann Zee, Netherlands November 12, 2010

  2. Complementary, Alternative, and Integrative Medicine • Medical and health care practices that are: -Outside the realm of conventional medicine - Much yet to be validated using scientific methods • Complementary:with conventional practices • Alternative: in place of conventional practices • Integrative:embraces best ofconventional & complementary as well as whole person care

  3. Integrative Medicine The practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, healthcare professionals and disciplines to achieve optimal health and healing Consortium Academic Health Centers for Integrative Medicine, 2004

  4. CAM Domains Source: http://nccam.nih.gov

  5. Outline • Rationale for including Complementary/Integrative Medicine (CAM/IM) in the Medical Curriculum • Using CAM/IM in the Learning of Science • Using CAM/IM to Foster Professionalism

  6. Widespread public usage Why is CAM/IM Important for the Training of Physicians?

  7. CAM Use in the United States Barnes et al., CDC NHS # 12 2008

  8. Why Patients Use Complementary/Integrative Medicine • Value whole person emphasis • Conventional treatment did not work • Adverse effects of orthodox medicine • Seek active participation in treatment • Poor doctor communication Vincent J Why patients turn to complementary medicine. An empirical study. Brit J Clinical Psychology 35:37-48 1996

  9. But The Real Problem is… <40%of therapies used were disclosed to the physician (Eisenberg DM et al Trends in Alternative Medicine use in the United States: 1990-1997; results of a follow-up national survey, JAMA, 1998)

  10. Widespread public usage Growing awareness/desire by students and faculty to include CAM/IM in medical training Why is CAM/IM Important for the Training of Physicians?

  11. CAM practices should be included in my school's curriculum. 100 90 80 70 First Years 60 Second Years Percentage (n=266) 50 40 32.3 31.6 29.7 30 25.2 22.5 17.4 20 11.7 8.4 10 5.4 5.2 3.6 2.6 1.9 1.8 0.6 0 No Answer Disagree Somewhat Neutral Somewhat Agree Strongly Strongly Disagree Disagree Agree Agree Chaterji et al Alt Ther Health Med 2007

  12. Desire for Future CAM Training First and Second Year Students Sufficient to Personally Therapeutic/Healing Touch Provide Sufficient to Advise Patients Rolfing (Structural Reintegration) About Use Meditation None No Answer Prayer/Spiritual Healing Nutritional Supplements Music Massage Hypnosis/Guided Imagery Homeopathy Herbal Medicine Chiropractic Biofeedback Bioelectromagnetic Therapies Aromatherapy Acupuncture 0 10 20 30 40 50 60 70 80 90 100 Response(%) Chaterji et al Alt Ther Health Med 2007

  13. Desire for Future Training >50% of the students would like enough knowledge to • personally provide their patients: • Nutritional supplements • advise their patientson: • Acupuncture • Herbal medicine • Chiropractic • Massage Chaterji et al Alt Ther Health Med 2007

  14. 15 NIH-Funded (R25 Grants) for CAM Curricular Initiatives (2000-2003) National Efforts Addressing CAM Integration in Education

  15. Children’s Hospital – Boston Rush College of Nursing University of Minnesota University of North Carolina University of Texas - Galveston Georgetown University Maine Medical Center Tufts University University of Michigan University of Washington Oregon Health Sciences University U California - San Francisco University of Kentucky University of Washington School of Nursing American Medical Student Association U California - Irvine U Connecticut U Massachusetts Kansas City University Louisiana State University University of Texas at San Antonio NCCAM R25 Grant Institutions

  16. Special Series for Academic Medicine October 2007Education in Complementary and Alternative MedicineEditorial Group: Aviad Haramati, PhD, Chair, William Elder, PhD, Margaret Heitkemper, RN, PhD, Nancy Pearson, PhD, Sara Warber, MD • Preface: Insights from Educational Initiatives in CAM • The CAM Education Program from NCCAM: An Overview • Rationales for CAM Education in Health Professions Training Programs • What Should Students Learn about CAM? • Incorporation of CAM into Health Professions Education: Organizational and Instructional Strategies • Barriers, Strategies, and Lessons Learned from CAM Curricular Initiatives • Using CAM Curricular Elements to Foster Medical Student Self-awareness • Evaluating CAM Education in Health Professions Programs • Collaboration Between Allopathic and CAM Health Professionals: Four Initiatives

  17. 15 NIH-Funded (R25 Grants) for CAM Curricular Initiatives (2000-2003) Consortium of Academic Health Centers for Integrative Medicine (est. 2002) National Efforts Addressing CAM Integration in Education

  18. 1999: 8 Institutions University of Minnesota University of Massachusetts University of California, San Francisco Harvard University Stanford University University of Maryland Duke University University of Arizona

  19. 2010: 46 Members University of California, Irvine University of California, Los Angeles University of California, San Diego University of California, San Francisco University of Chicago University of Kansas University of Maryland University of Massachusetts University of Medicine &Dentistry of New Jersey University of Michigan University of Minnesota University of New Mexico University of North Carolina, Chapel Hill University of Cincinnati University of Pennsylvania University of Pittsburgh University of Texas University of Vermont University of Washington University of Wisconsin Vanderbilt University Wake Forest University Yale University Albert Einstein/Yeshiva University Boston University Columbia University Duke University Georgetown University George Washington University Harvard Medical School Johns Hopkins University Laval University, Quebec Mayo Clinic McMaster University, Ontario Northwestern University Ohio State University Oregon Health & Science University Stanford University Thomas Jefferson University University of Alberta University of Arizona University of Calgary     University of Colorado University of Connecticut University of Hawaii University of Illinois

  20. Academic Consortium’s Educational Projects in Medical Curricula • Kligler, B et alCore Competencies in Integrative Medicine for Medical School Curricula: A ProposalAcademic Med 79:521-531, 2004 • A Guide for Medical Educators: Curriculum in Integrative Medicine - Sample Modules www.imconsortium.org

  21. NIH-Funded Institutions (R25 Grants) Undertaking Curricular Initiatives (15) Consortium of Academic Health Centers for Integrative Medicine (30) (est. 2002) Policy Initiatives: White House Commission on CAM Policy (2002) National Policy Dialogue Report (2002) IOM Committee on CAM (Jan 2005) National Education Dialogue (June 2005) IOM: Integrative Medicine and Health (2009) National Efforts Addressing CAM Integration in Education

  22. IOM Study on CAM Recommendation on Education “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…to enable licensed professionals to competently advise their patients about CAM.” Report Issued: January 12, 2005

  23. Canada: CAM in UME Task Force • All 17 Medical Schools Participating • Task Force convened 2000 • Goal: To develop a guide for implementing CAM integration in UME • Consensus regarding core competencies • Digital repository of curricular materials www.caminume.ca

  24. THE SCOTTISH DOCTOR Learning Outcomes 3rd Edition – April 2008 What the doctor is able to do - Technical Skills How the doctor approaches their practice The doctor as a professional Clinical Skills Practical Procedures Patient Investigation Patient Management Communication Skills Health promotion and Disease Prevention Medical Informatics Learning Outcomes for Patient Management – Complementary Therapies • Appreciation of what is available in the form of complementary therapies and the evidence-base for them • Outline of what is involved in most commonly practised therapies; how alternative and conventional therapies might be combined • Keeping an open mind and remaining non-judgmental regarding the use of complementary therapies

  25. Broad objective By the end of the project period, all graduates of Georgetown University School of Medicine will have an improved level of awareness about CAM information and practices, so that they will be able to understand and follow advances in CAM, as well as advise and communicate more effectively with their patients Educational Initiative in CAMat Georgetown U School of Medicine

  26. Educational Initiative in CAMat Georgetown U School of Medicine Goals for Implementation • Knowledge about CAM • Skills and Attitudes about CAM • Enhancing the Research Environment in CAM

  27. Widespread public usage Growing awareness/desire by students and faculty to include CAM in medical training Incorporation of CAM-relevant material can help address several desired goals in the medical curriculum Why is CAM/IM Relevant to the Training of Physicians?

  28. Using CAM to Advance… • Knowledge– Understanding the scientific basis for various CAM therapies; interactions (herb-drug)

  29. Educational Initiative in CAMat Georgetown U School of Medicine Examples of Basic Science Integration • Gross Anatomy:anatomy of acupuncture, massage • Human Physiology: biofeedback, neuromuscular manipulation • Human Endocrinology:Stress reduction: imagery, meditation, breathing • Neuroscience: mechanisms of acupuncture action • Immunology: psychoneuroimmunology • Pharmacology: botanicals, dietary supplements, herb-drug interactions

  30. Using CAM to Advance… • Knowledge– Understanding the scientific basis for various CAM therapies; interactions (herb-drug) • Skills – Analytic Skills: Rules of Evidence, Stress Management Skills, Self-Awareness with Mind-Body Medicine Skills, Clinical Skills: OSCE Station • Attitudes – Improvements in patient-doctor communication, open-mindedness • Values – Emphasis on relationship-centered care, respect for CAM disciplines/practitioners

  31. Hierarchy of Evidence Guidelines Systematic reviews Rigorous human studies Basic biological understanding Courtesy of Dr. Josie Briggs, NCCAM

  32. *Number of CAM RCTs Indexed on MEDLINE, 1982-2008. We used the following search strategy to obtain counts for each year: CAM [subset] AND randomized-controlled-trial [subset] AND year [Publication Date]. Searches were run on Oct. 22, 2009. Courtesy of Eric Manheimer

  33. CAM Field of Cochrane Collaboration:Databases of Controlled Trials and Systematic Reviews • Over 21,000 controlled clinical trials of complementary therapies have been identified and published in The Cochrane Library (as of Issue 3, 2008) • 300 CAM-related Cochrane reviews have been completed and are published in The Cochrane Library (as of Issue 3, 2008) • 201 CAM-related Cochrane review protocols are published in The Cochrane Library (as of Issue 3, 2008) Courtesy of Eric Manheimer

  34. *Number of CAM SRs Indexed on MEDLINE, 1982-2008. We used the following search strategy to obtain counts for each year: CAM [subset] AND systematic [subset] AND year [Pulication Date]. Searches were run on Oct. 22, 2009. Courtesy of Eric Manheimer

  35. Practice Guidelines Journal of Manipulative and Physiological Therapeutics Systematic Review RCT Courtesy of Dr. Josie Briggs, NCCAM

  36. At the 2009 Conference in Minneapolis, MN (May 12-15, 2009)Goal:To highlight recent research and state-of-science across disciplines6 keynote speakers33 scientific sessions (symposia, featured discussions, workshops)57 oral abstracts (top 15% of all abstracts)>250posters (basic science, clinical, health services, methodology, and education)Research Resource sessions for trainees/new investigatorsOver 800 registrants and 26 Participating Organizations

  37. Graduate Studies in CAM at Georgetown University M.S. in Physiology Directors HakimaAmri, PhD, Assistant Professor Aviad Haramati, PhD, Professor Program Coordinator AurellerCabiness, MA

  38. Mission • To educate open-minded health care providers and scientists eager to explore the state of the evidence in areas of complementary and integrative medicine with objectivity and rigor.

  39. Goals of the Program • Core Foundation in Science • Systems Physiology, Cell and Molecular Physiology • Physiology of Mind-Body Medicine • Human Nutrition, Herbs, Supplements • Pathophysiology and Mechanisms of Disease • Research Methodology, Biostatistics • Broad Exposure to CAM (Complementary, Alternative, Integrative) • Survey of CAM Disciplines, Philosophies and Therapeutic Approach • Competence in Assessment of Evidence • Research literacy • Objectivity and Rigor in Evaluating Data • Safety and Efficacy of CAM Therapies • Understanding bias

  40. Tai Chi for Fibromyalgia Courtesy of Dr. Josie Briggs, NCCAM

  41. “But what is the active element of a complex, multi-component therapy such as tai chi? Is it rhythmic exercise, deliberate and deep breathing, contemplative concentration, group support, relaxing imagery, a charismatic teacher, or some synergistic combination of these elements?” “If so, would the matched control include awkward movements, halted breathing, participant isolation, unpleasant imagery, or a tepid teacher? Would the resulting sham intervention be credible, valid, or even genuinely inactive?” Gloria Y. Yeh, M.D., M.P.H., Ted J. Kaptchuk, and Robert H. Shmerling, M.D. Prescribing Tai Chi for Fibromyalgia — Are We There Yet? N Engl J Med 2010; 363:783-784 Courtesy of Dr. Josie Briggs, NCCAM

  42. Outline • Rationale for including Complementary/Integrative Medicine (CAM/IM) in the Medical Curriculum • Using CAM/IM in the learning of Science • Using CAM/IM to Foster Professionalism

  43. Mission Statement Guided by the Jesuit tradition of cura personalis, of caring for the whole person, Georgetown University School of Medicine will educate, in an integrated way, knowledgeable, skillful, ethical, and compassionate physicians and biomedical scientists dedicated to the care of others and the health needs of our society. Georgetown University School of Medicine

  44. Women Men Decline in Empathy in Medical School Newton et al Academic Med 83:244-249, 2008

  45. 1. Effective Communication 2. Basic Clinical Skills 3. Using Basic Science in the Practice of Medicine 4. Diagnosis, Management and Prevention 5. Life-long Learning 6. Self-Awareness, Self-Care, and Personal Growth 7. Social/Community Contexts of Healthcare 8. Moral Reasoning and Clinical Ethics 9. Problem-solving Competency-Based Medical Education

  46. What the doctor is able to do - Technical Skills How the doctor approaches their practice The doctor as a professional THE SCOTTISH DOCTOR Learning Outcomes Clinical Skills Practical Procedures Patient Investigation Patient Management Communication Skills Health promotion and Disease Prevention Medical Informatics Basic, Social, Clinical Sciences, Underlying Principles Attitudes, Ethics, Legal Responsibilities Decision Making Skills , Clinical Reasoning, Judgment Personal Development Self-awareness, Self-care, Commitment Role of the Doctor within the Health Service

  47. Educational Initiative in CAMat Georgetown U School of Medicine Specific Aim • To increase student understanding of self-awareness and self-care by providing a unique experiential and didactic introduction to Mind-Body Medicine

  48. Goal of Mind-Body Medicine Skills Program Mind-Body approaches are not only effective in helping to reduce stress and anxiety, but also teach the power of self-awareness and self-care. In order for students to understand the potential and applicability of mind-body approaches in healthcare, we believe it is important for them to experience these techniques and gain insight about themselves. Educational Initiative in CAMat Georgetown U School of Medicine

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