Response to a proposal for an integrative medicine curriculum.

BACKGROUND: A paper entitled "Core Competencies in Integrative Medicine for Medical School Curricula: A proposal," published in Academic Medicine, stimulated a broad discussion among complementary and alternative medicine (CAM) educators. This discussion led to a formal process for responding to the issues raised by the paper. METHODS: Representatives from the Academic Consortium for Complementary and Alternative Health Care (ACCAHC) and the Oregon Collaborative for Complementary and Integrative Medicine (OCCIM) formed the ACCAHC/OCCIM Task Force to participate in a Delphi process of consultation and deliberation. This process led to a broad, cross-discipline agreement on important points to include in a response to the integrative medicine (IM) curriculum proposal. RESULTS: Five key areas of concern emerged: (1) the definition of IM as presented in the paper; (2) lack of clarity about the goals of the proposed IM curriculum; (3) lack of recognition of the breadth of whole systems of health care; (4) omission of competencies related to collaboration between MDs and CAM professionals in patient care; and (5) omission of potential areas of partnership in IM education. CONCLUSIONS: A major overall theme emerging from the Delphi process was a desire for closer collaboration between conventional medical schools and CAM academic institutions in developing IM curricula. Several cross-disciplinary venues for addressing the Delphi Task Force themes include the National Center for Complementary and Alternative Medicine's R-25 Initiatives, and the National Education Dialogue. OCCIM is presented as an example of a successful lateral integration approach.

Evaluating CAM education in health professions programs.

As medical, nursing, and allied health programs integrate complementary and alternative medicine (CAM) content into existing curricula, they face many of the same challenges to assessment and evaluation as do more traditional aspects of health professions education, namely, (1) specifying measurable objectives, (2) identifying valid indicators, and (3) evaluating the attainment of desired outcomes. Based on the experiences of 14 National Center for Complementary and Alternative Medicine (NCCAM) education grant recipients funded between 2000 and 2003, the authors cite selected examples to illustrate strengths and deficits to "mainstreaming" CAM content into established health professions curricula, including subjecting it to rigorous, systematic evaluation. In addition to offering recommendations for more strenuously evaluating key CAM-related educational outcomes, the authors discuss related attitudes, knowledge, and skills and how these, like other aspects of health professions training, may result in enhanced patient care through modifications in clinical (provider) behaviors.

Collaborations between allopathic and complementary and alternative medicine health professionals: four initiatives.

An effort to increase the understanding of complementary and alternative medicine (CAM) by health care professionals requires an interdisciplinary and collaborative approach. Between 2000 and 2002, National Institutes of Health National Center for Complementary and Alternative Medicine funded 15 educational institutions to develop curricular models for educating allopathic medical and nursing learners in CAM literacy. Four of these 15 programs, Tufts University School of Medicine, University of California at San Francisco School of Medicine, Oregon Health & Sciences University School of Medicine, and University of Washington School of Nursing, formed collaborative partnerships with nearby academic institutions that train CAM practitioners. This article focuses on these four examples of institutional collaboration, summarizing the challenges faced and the positive outcomes achieved for learners, faculty, and institutions. As collaborations between such institutions increase, future potential directions for consideration include credentialing of CAM practitioners teaching within allopathic health professional institutions, faculty development within existing allopathic health professional schools on incorporating evidence-based CAM content into their standard allopathic education, and viewing CAM as an aspect of cultural sensitivity.

Implications for education in complementary and alternative medicine: a survey of entry attitudes in students at five health professional schools.

INTRODUCTION: The National Institutes of Health provided grants to the Oregon Health & Science University (OHSU) and 14 other allopathic academic health centers for the development of curricula in complementary and alternative medicine (CAM). A key component of the curriculum evaluation for OHSU was provided by a survey assessing attitudes toward CAM and selected personality characteristics of entering students in chiropractic, naturopathic, Oriental, and allopathic medicine in the Pacific Northwest and Upper Midwest. METHODS: A survey containing a variety of assessments of attitudes toward CAM and the personality traits of adventurousness and tolerance to ambiguity was administered to students entering four Portland, Oregon doctoral-level health professional schools and an allopathic medical school in the Upper Midwest (University of Nebraska College of Medicine) during the 2004-2005 academic year. RESULTS: Students of naturopathy (n = 63) and Oriental Medicine (n = 71) were the most "CAM positive," adventurous and tolerant of ambiguity, and Midwestern allopathic medical students (n = 58) the least. In general, chiropractic students (n = 89) and allopathic medical students from the Pacific Northwest (n = 95) were intermediate in CAM attitudes between these two groups (all p < 0.05). Female students were more "CAM positive" in all schools compared to male students. CONCLUSIONS: Students have high levels of interest in CAM upon entrance to their schools. Health professional discipline, geographic location, personality qualities, and gender appear to influence CAM attitudes in entering students.

Complementary and alternative therapies for the management of menopause-related symptoms: a systematic evidence review.

BACKGROUND: Nearly half of adults in the United States use complementary and alternative therapies each year for a variety of reasons. These therapies are increasingly popular among women seeking alternatives to treatment with estrogen for managing menopausal symptoms. The objective of this review was to assess the effectiveness of complementary and alternative therapies in the management of menopausal symptoms. DATA SOURCES: MEDLINE, PsychINFO, Cochrane Library database, MANTIS, and AMED. STUDY SELECTION: Full-text, English-language, randomized controlled trials and meta-analyses comparing a complementary or alternative therapy with placebo or control for treatment of menopausal symptoms. DATA EXTRACTION: All eligible trials were reviewed, abstracted into evidence tables, and rated for quality. DATA SYNTHESIS: Seventy randomized controlled trials met inclusion criteria. Forty-eight studies of phytoestrogens and other biologically based agents showed mixed results. Smaller numbers of studies using mind-body, energy, manipulative, and body-based therapies and whole medical systems showed little benefit in treating menopausal symptoms. CONCLUSIONS: Although individual trials suggest benefits from certain therapies, data are insufficient to support the effectiveness of any complementary and alternative therapy in this review for the management of menopausal symptoms. Many of these potential therapies warrant further study in trials with rigorous scientific designs to determine benefit and safety.

Status of credentialing alternative providers within a subset of U.S. academic health centers.

BACKGROUND: Complementary and alternative medicine (CAM) clinical services are increasingly provided within conventional health care settings. OBJECTIVE: To determine how a subset of U.S. academic health centers is credentialing CAM providers. DESIGN: An electronic survey was created focusing on the credentialing method utilized for six specific types of CAM clinical practitioners within academic medical settings. METHODS: This survey was electronically distributed to 33 academic health centers in the United States during the summer 2004. RESULTS: Ninety-five percent (95%) of academic centers surveyed provide some CAM clinical care. Acupuncture and massage are most common, with naturopathy and homeopathy least common. State licensure requirements for CAM providers appear to not be well-understood. Most commonly, CAM professionals do not receive full medical staff credentials. LIMITATIONS: Results cannot be extrapolated to remaining academic health centers within the United States. Mind-body practitioners were not included in the survey. CONCLUSIONS: Credentialing and privileges are most commonly granted via indirect methods. Variability in state licensure compounds the challenge of credentialing CAM practitioners. Suggestions for beginning discussions on guiding principles for integrating CAM practitioners within conventional settings are proposed.

Nonhormonal therapies for menopausal hot flashes: systematic review and meta-analysis.

CONTEXT: Concern regarding the adverse effects of estrogen and other hormones for treating menopausal symptoms has led to demand for other options; however, the efficacy and adverse effects of nonhormonal therapies are unclear. OBJECTIVE: To assess the efficacy and adverse effects of nonhormonal therapies for menopausal hot flashes by reviewing published randomized controlled trials. DATA SOURCES: MEDLINE (1966-October 2005), PsycINFO (1974-October 2005), and the Cochrane Controlled Clinical Trials Register Database (1966-October 2005) were searched for relevant trials that provided data on treatment of menopausal hot flashes using 1 or more nonhormonal therapies. STUDY SELECTION: All English-language, published, randomized, double-blind, placebo-controlled trials of oral nonhormonal therapies for treating hot flashes in menopausal women measuring and reporting hot flash frequency or severity outcomes. DATA EXTRACTION: Trials were identified, subjected to inclusion and exclusion criteria, and reviewed. Data on participants, interventions, and outcomes were extracted and trials were rated for quality based on established criteria. A meta-analysis was conducted for therapies with sufficient trials reporting hot flash frequency outcomes. DATA SYNTHESIS: From 4249 abstracts, 43 trials met inclusion criteria, including 10 trials of antidepressants, 10 trials of clonidine, 6 trials of other prescribed medications, and 17 trials of isoflavone extracts. The number of daily hot flashes decreased compared with placebo in meta-analyses of 7 comparisons of selective serotonin reuptake inhibitors (SSRIs) or serotonin norepinephrine reuptake inhibitors (SNRIs) (mean difference, -1.13; 95% confidence interval [CI], -1.70 to -0.57), 4 trials of clonidine (-0.95; 95% CI, -1.44 to -0.47), and 2 trials of gabapentin (-2.05; 95% CI, -2.80 to -1.30). Frequency was not reduced in meta-analysis of trials of red clover isoflavone extracts and results were mixed for soy isoflavone extracts. Evidence of the efficacy of other therapies is limited due to the small number of trials and their deficiencies. Trials do not compare different therapies head-to-head and relative efficacy cannot be determined. CONCLUSION: The SSRIs or SNRIs, clonidine, and gabapentin trials provide evidence for efficacy; however, effects are less than for estrogen, few trials have been published and most have methodological deficiencies, generalizability is limited, and adverse effects and cost may restrict use for many women. These therapies may be most useful for highly symptomatic women who cannot take estrogen but are not optimal choices for most women.

Development of an integrative patient history intake tool: a Delphi study.

OBJECTIVE: To identify patient history intake questions common to four fields of medicine--allopathic, naturopathic, chiropractic, and Traditional Chinese Medicine for potential development of an Integrative Patient History Intake Tool. DESIGN: A two-round modified Delphi technique was utilized to generate expert consensus among Oregon healthcare practitioners on the importance of specific patient history intake questions. A panel of faculty members from Oregon Health & Sciences University (OHSU), the National College of Naturopathic Medicine (NCNM), the Oregon College of Oriental Medicine (OCOM), and Western States Chiropractic College (WSCC) identified 321 patient history intake questions, which then were distributed to 106 Oregon healthcare practitioners. The healthcare practitioners were asked to rate the importance of each question through a series of two surveys over the period of 11 weeks. Suggestions for additional intake questions also were invited. RESULTS: The Delphi process resulted in the original 321 initial questions plus 150 additional suggested questions being reduced to 52 intake questions (11% total similarity) for the potential development of the Integrative Patient History Intake Tool. There was a 63% response rate to SURVEY I, and a 73% response rate for SURVEY II. CONCLUSION: The concept of attempting to develop an integrative patient history intake tool is important to improve communication between practitioners of allopathic, naturopathic, chiropractic, and Traditional Chinese Medicine. This study revealed insight into the difficulties faced with such a tool due to the lack of similarity in priorities of questions between these different disciplines. This may also reveal a component of why communication remains difficult between these fields, but should not deter efforts to increase communication in the interest of optimal patient care.