EDCAM - CAM and Medical Education Report

Medicine today is experiencing a paradigm shift that involves the blending of two disparate philosophies of health and disease, the biomedical or scientific reductionist view and the clinical, experiential holistic view. While the biomedical model reduces disease to a disturbance in biochemical processes and relies heavily on the "curative model" of care, holistic medicine derives from a "healing model," which emphasizes the complex interplay between multiple factors: biochemical, environmental, psychological, and spiritual. ⁱ

Over the past century, support for the biomedical model derived from its immense success in treating acute illness and conquering infectious disease. Current healthcare providers are faced with the equally challenging issues of health promotion, disease prevention and management of chronic illnesses for which conventional medicine has offered only limited success. ^ii,iii Many allopathic physicians now readily accept mind-body approaches such as biofeedback, music therapy, and hypnosis. These practices, once considered unconventional, have been shown to be efficacious and are now assimilated into current standards of care. ^iv

Consistent with their preference for holistic medical care, an increasingly knowledgeable patient population is now fueling the CAM movement by seeking alternatives to traditional treatments. These therapies include, but are not limited to, acupuncture, massage therapy, herbal medicines and mind-body techniques. Recent trends indicate an increase in the use of CAM modalities between 1990 and 1997 from 34% to 42% of the general population. In addition, the total number of visits to CAM providers increased from 427 million to 629 million within this same time period. This number exceeds the total visits to all primary care physicians combined (386 million) in 1997. ^xxiii

In academia, while alternative therapies were readily dismissed by physicians as fringe medicine just a decade ago, alternative medicines are now beginning to earn mainstream attention and academic stature. ^v The growing number of CAM clinics affiliated with hospitals, the expansion of CAM courses within academic medical education, and the increase in CAM benefits offered by insurers offer clear evidence of this trend. ^vi As this trend is in line with AMSA's mission for humanistic and patient care-based education, it hopes to contribute toward this growth through its CAM Education Initiative.

The reasons patients seek CAM must be understood by a physician seeking to collaborate with a patient in his/her health care. Whether it is because of cultural beliefs, logical concerns about side effects and nosocomial damage, ^vii the emphasis on meaning and context for their illness rather than proof of efficacy of particular treatments, ^viii knowledge that physicians' acumen in CAM is limited, or the need for empowerment during the disease-treatment process ^ix patients are seeking solutions that make sense to them. When patients feel properly counseled by their physicians, they are more likely to reconsider modalities found to be unsafe or ineffective. ^xvi Furthermore, true integral health care supports greater patient responsibility for prevention and self-care. ^x When these patients are unable to pursue alternatives without being ridiculed or blindly dissuaded, patients choose not to inform their physicians about their use of CAM. In fact, research indicates that less than 40% of patients disclose their use of alternative therapies to their physicians. ^xxiii This lack of communication puts patients at potential risk of serious health effects, particularly among herbal medicines, supplements, and pharmaceutical drugs. ^xi

Cultural Competence

Medically underserved populations, particularly minorities, demonstrate higher rates of morbidity and mortality. ^xii Racial and ethnic disparities in health care are prominent and have been clearly identified by the Surgeon General's Healthy People Project. ^xiii For example, African American men have a 47% higher incidence of prostate cancer and a 128% higher mortality rate than comparable groups of white men. ^xiv According to the U.S. Census Bureau, minority populations in the U.S. have increased by more than 15% between 1990 and the year 2000; racial and ethnic disparities can be expected to continue growing if this issue is not properly addressed. ^xv

National efforts to address the role of cultural competency in health care is evidenced by the AMA Policy Compendium that expresses "zero tolerance" of racial and ethnic disparities in health care. ^xii The AMA Council in Medical Education offers recommendations for "Enhancing the Cultural Competence of Physicians," which includes the following description of the hallmarks of a culturally competent clinician:

• Knowledge of patients' healthcare belief systems and how they affect medical care;
• Skills to communicate with sensitivity toward cultural issues, to understand the patient's perspective, and to formulate culturally sensitive treatment plans; and
• Attitudes that demonstrate empathy and respect for other views regarding health and illness. ^xvi

The AMA's Council on Ethical and Judicial Affairs stresses that academic and other medical institutions should offer educational programs about gender and cultural issues to staff and physicians-in-training. ^xvii These policies reflect the Association's understanding that knowledge and tolerance of cultural diversity is integral to effective healthcare delivery. Health professionals who receive better training in cultural competency are more prepared to practice medicine in the inevitable environment of broadening cultural diversity. Lack of cultural competence contributes to racial and ethnic health disparities as culture has been shown to influence health-seeking behaviors, outcomes, quality of health care, and patient satisfaction. ^xviii Knowledge of the role of culture in health and disease allows the clinician to communicate more effectively within the context of their patients' healthcare belief systems. It is important to note that although the primary form of medicine practiced in the U.S. is conventional, approximately 75% of the world's health care would be considered alternative by conventional U.S. standards according to the World Health Organization. ^xix

Medical Education

Because of the widespread use of CAM by patients, and the growing scientific evidence that certain CAM therapies are more effective than orthodox alternatives, CAM education must be integrated into medical education in allopathic and osteopathic schools in the near future. Medical school educators and administrators have steadily expanded and restructured the curriculum over the past 30 years as new innovations and evidence have emerged. They have introduced teaching of sex education, laparoscopy, gene therapy, immunology, AIDS/HIV, and neurosciences. It is now time that the curricula nationwide recognize the importance and pervasiveness of CAM in the medical system already. Schools must recognize the demand and importance of making future doctors aware of new techniques and other paradigms of healing which are used by healthcare providers in other parts of the world.

Medical education reform will undoubtedly require an increase in learning through curiosity and exploration, the social aspects of medicine and adaptation to changing patterns in health care. ^xxiv In order to implement real change, "medical schools must (1) take the long view, making reform part of the entire continuum of medical education; (2) ensure that faculty physicians teach by example; (3) change student assessments to reflect new educational objectives; and (4) reallocate resources to support a changed curriculum." ^xx A commitment to respond to societal needs and expectations is of greatest importance in directing changes in the training of future physicians. ^xxi

Many medical schools have attempted to incorporate CAM education as elective courses. Recent studies report that 64% of U.S. medical schools offer such courses. ^xxiii It is important to note the tremendous heterogeneity that exists in both content and requirement among schools. Development of a more consistent educational approach is necessary if future physicians are to be adequately prepared for their role as culturally competent, integrative medical care providers.

Medical students have expressed tremendous support for the inclusion of CAM within traditional core curricula. According to 2002 AAMC Medical School Graduation Questionnaire results, 50% of medical students rated their education in alternative medicine to be "inadequate." Interestingly, this number has not changed since 1998 despite the doubling of CAM elective courses offered at medical schools over the past two years, from 34 medical schools in 1996 to 75 schools in 1998. ^xxiii Clearly, CAM elective courses alone are not adequately preparing future physicians to advise their patients concerning treatments related to CAM. A recent report from the Association of American Medical Colleges calls for physicians to be sufficiently knowledgeable about both conventional and non-conventional modes of care. ^xxii

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