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Patients are increasingly using complementary and alternative medicine,1,2 and doctors are responding to this in several ways, from being enthusiastic and interested to mystified and critical.3–5 Complementary and alternative medicine incorporates several different approaches and methodologies,6 with techniques ranging from spiritual “healing” in cancer to nutritional interventions for premenstrual tension, acupuncture for pain relief, and manipulation for backache. In this article we encourage you to reflect on your understanding of complementary and alternative medicine in relation to your clinical practice, share some of the current initiatives in undergraduate and postgraduate familiarisation and training in this type of medicine, and explore the implications of education, support, and development.
The BMA's attitude to complementary and alternative medicine became much more positive between its first and second reports on the subject in 1986 and 1993.7 Around 39.5% of general practice partnerships in England provide access to some form of complementary therapy for their NHS patients,8 but this raises questions about how the provision of such treatment can be integrated into conventional practice. If the care is provided on a delegated or referred basis, how much does a doctor need to know to make appropriate referrals and supervise delegated treatment? If doctors are to treat patients with complementary and alternative medicine what training do they require?
Until recently few medical students would have been familiar with complementary and alternative medicine, despite being interested in it.9–12 Over the past few years there has been a major increase in courses familiarising students with complementary and alternative medicine.13,14 The opportunity to integrate this training into the undergraduate curriculum has been facilitated by giving students options in special study modules15 and noting what they want to learn. At the University of Southampton the module in complementary and alternative medicine has been running for five years as part of the special study modules for medical students in their third year. It grew out of the students' request for familiarisation with this type of medicine (mirroring the demand for such therapy by patients). The medical school actively supports the presence of its small research unit in complementary and alternative medicine.
Southampton's module in complementary and alternative medicine is an opportunity to revisit basic assumptions about attitudes and values in medicine through a reflective learning process. Although it helps to ask whether it works and to review its evidence base, a broader set of learning objectives (box) has been established through a consultation and ranking exercise.16 Themes that students regularly identify include treatments chosen by patients not doctors, patients with the same disease choosing different treatments, privately funded treatments, variety of standards of care, and lack of regulation within professions practising complementary and alternative medicine.
Southampton's special study module is made up of eight half day sessions. Modules in other medical schools are structured differently. Although there is no formal way of setting or agreeing objectives between medical schools, there has been a “sharing” of activities.17 Southampton's current teaching plan (box) looks at key therapies and gives a context in which to explore and interpret the use and provision of complementary and alternative medicine in the community in relation to conventional medicine. Our evaluations show that the needs of the students are addressed by this module18 and that the aims are meet; comments from students include “I wish I was the patient,” “I was surprised by the range of different illnesses patients had,” and “It left me interested to find out more.”
Over the past three years at Southampton student nurses and student chiropractors have taken the module. This enables different professional views and values about both conventional and complementary and alternative medicine to be put forward, which in many ways parallels aspects of individualisation so important to complementary and alternative medicine. This multidisciplinary teaching has received positive feedback and encouraged us in developing further multiprofessional approaches to teaching complementary and alternative medicine.19
Several thousand doctors belong to medical organisations offering training, accreditation, and regulation in complementary and alternative medicine (see Appendix). Training focuses on two main levels, a basic or primary healthcare qualification, which gives an introduction to a subject and provides skills to work with a basic level of competence, such as the Faculty of Homoeopathy's primary healthcare certificate, or the British Medical Acupuncture Society's basic training. These usually involve four or more days of training combined with home study over a year. This leads on to intermediate training and full membership, usually involving a further two years of part time teaching and home study. Although many specialists in complementary and alternative medicine work in primary care, a third level of specialist training based on supervised experience is also emerging. Examinations and other assessments evaluate competence, and most medical organisations in complementary and alternative medicine are developing a programme of continuing professional development.
Homoeopathy is one of the most established complementary and alternative medicines in that it has been incorporated into the NHS since its inception. Five NHS homoeopathic hospitals now exist as well as a Faculty of Homoeopathy established by an act of parliament. The Faculty of Homoeopathy has 300 full members and 406 members at the primary healthcare level. The British Medical Acupuncture Society has grown greatly over the past decade and includes over 1700 basic and 500 full or accredited members, who incorporate acupuncture into their normal medical practice.
Session 1: introduction and overview of basic principles of complementary and alternative medicine
Session 2: hypnosis and herbalism
Session 3: acupuncture and osteopathy
Session 4: homoeopathy and aromatherapy
Session 5: clinical attachment or visit to a college of chiropractic
Session 6: clinical attachment
Session 7: clinical problem solving with complementary and alternative medicine
Session 8: dilemmas and opportunities—assessment and review
Doctors give a variety of reasons for undertaking a course in complementary and alternative medicine, from feeling a responsibility to respond to their patients' interests and needs to developing “another string to their bow.” Some are attracted to its study in its own right, others by a wish to focus some of their energy away from conventional medical practice, which they may find stressful and unfulfilling. Doctors studying complementary and alternative medicine often call on different personality traits20 and report a variety of positive benefits from training, including welcoming the opportunity to engage their feelings, trust their intuition, and enjoy therapeutic touch. Comments from attendees at one homoeopathic course were “I started to enjoy seeing patients again,” “Training had improved my conventional history taking,” and “Having another approach made treating heart-sink patients easier.”
Retraining leads to a re-examination of how practitioners relate to patients and a rethinking of their clinical work, as well as the professional organisation they feel at home in for support and development. Griffiths and Tann argue that a practitioner's values and personal theories translate through practice into the external theory of a profession,21 and in complementary and alternative medicine there are several emerging professional groups. Several doctors seem to be integrating complementary and alternative medicine into their clinical management,8 but a proportion of these have been on no or only brief training courses.22 The BMA and General Medical Council have recommended that doctors providing complementary and alternative medicine are adequately trained.7 Those doctors who engage patients more through their emotions need regular support and supervision to help with the practice and development of their professional work.23 Doctors integrating complementary and alternative medicine into their work and working as specialist practitioners of such medicine also need professional support to integrate their developing approach into practice, particularly if it is different from their colleagues. Unfortunately it is often the case that emerging professional groups lack infrastructure, practical support, and funding to provide supervision and mentoring when it is most needed.
Establishing a module in complementary and alternative medicine within the undergraduate curriculum made us call on those outside the circles of conventional medicine, with input from students and the medical school, to build a teaching team that shared core values. We have been impressed by the benefits students have had from attachments to local providers of complementary and alternative medicine, and this has brought a network of practitioners into contact with the medical school. Such contact could be an important step in the integration of complementary and alternative medicine with other medical services. The issues that are raised by complementary and alternative medicine model many dilemmas for communities relating to changes within medical practice, including prioritising funding, obtaining relevant evidence, respecting individual choice, and provision for minority groups. For doctors and students it raises questions about clarifying and working within their limits of competence, how patients' expectations alter, and a way that doctors can develop new skills. Looking ahead, we believe that there are opportunities for providing more multidisciplinary teaching, perhaps even an important common core element shared by all professionals in complementary and alternative medicine and conventional health care. From the patient's point of view, having specially trained doctors may be of great value in integrating complementary and alternative medicine and conventional medicine while making the training in complementary and alternative medicine yet more professional.
An opportunity exists for doctors to incorporate different approaches that can balance their own personal values and help in developing their individual model of health. This may be inspiring and allow doctors to re-engage enthusiastically with their patients. However, a move into an individualised way of working, with the possibility of using several different interventions for the same clinical condition, creates problems in the context of managed care.
The organisations providing education, development, and support for these doctors are stretched by, and may have conflicts in, providing, training, accreditation, and regulation in each discipline. These issues, along with the lack of statutory regulation in complementary and alternative medicine, will need to be addressed to allow the continued development of the professions in complementary and alternative medicine outside and within medicine.
If doctors are to have a role in gatekeeping or advising patients about complementary and alternative medicine they need some familiarisation with this type of medicine. Doctors and their professional organisations need to address the extent to which they will integrate the techniques of complementary and alternative medicine into their patient care. If they choose not to then it is likely that the provision of complementary and alternative medicine will continue to be patchy and largely outside the conventional care framework, perhaps through a growing network of parallel care providers involving larger numbers of non-medically qualified practitioners, which patients will continue to access directly. For doctors, familiarisation with and training in complementary and alternative medicine provides an opportunity to integrate different approaches into patient management and offers a framework to work with and develop other skills. These approaches enhance patients' care and meet some doctors' intuitive needs to balance the increase in the technological base of conventional medical approaches with a softer approach to clinical care. We believe that the integration of complementary and alternative medicine gives doctors and the health profession an opportunity to bring together the strengths and to balance the weaknesses inherent in different systems of health care, representing a coming together of the heart, head, and hand. Could this be a healing process in itself?
We thank the BMA for the Joan Dawkins education award and the British Homoeopathic Association for a charitable grant to assist with teaching costs; we also received support from the department of medical education at Southampton University's school of medicine. DKO is course organiser for the Southampton module in complementary and alternative medicine.
British Society of Allergy Environmental and Nutritional Medicine, PO Box 7, Knighton LD7 1WT (tel 01547 550380, fax 01547 550339, www.bsaenm.org.uk)
British Medical Acupuncture Society, 12 Marbury house, Higher Whitley, Warrington, Cheshire WA4 4QW (tel 01925 730727, fax 01925 730492, email ku.gro.erutcnupuca-lacidem@nimdA, www.medical-acupuncture.co.uk)
Faculty of Homoeopathy, 15 Clerkenwell Close, London EC1R 0AA (tel 020 7566 7800, fax 020 7566 7815, www.trusthomoeopathy.org)
Editorial by Berman
Competing interests: None declared.
Glasgow's special study module in complementary and alternative medicine offers a slightly different slant from that at Southampton as described in Owen et al's paper. Glasgow students are likewise given the opportunity to experience complementary and alternative medicine in practice, explore individual therapies, and discuss their uses and implications. There is similar reference to the evidence base for different therapies and how orthodox and complementary modalities and attitudes can be integrated in the interest of caring for the whole person. But is there more to be learned than this? At Glasgow Homoeopathic Hospital, the answer is yes.
Southampton's module offers an “opportunity to revisit basic assumptions about attitudes and values through a reflective learning process.” This is the main emphasis of the Glasgow module, and complementary and alternative medicine merely provides another way of addressing these assumptions. The conventional degree course in medicine is designed to equip students with the tools to become doctors. Students are taught the science of medicine and how to ask questions to gain information, to perform basic practical procedures, and to use high tech investigations to gain yet more information. But are they taught the basic skills of human interaction? Are they shown how they can use their greatest resources—themselves—to facilitate human healing? If they do not have these basic skills how can they hope to use orthodox or complementary and alternative medicine to beneficial effect?
The Glasgow module is entitled “Human healing” and is designed to pose more questions than it answers and to challenge our pre-existing ideas. What is human healing? How does it happen, and how can we study it? What is already known? How can we, as doctors, influence healing? Many such issues are addressed by studying the therapeutic consultation, with debate and reflection promoted by Dr David Reilly, who devised the module and who facilitates most of the sessions. Students address which of their own personal qualities, attitudes, and prejudices may influence the outcome of a consultation, in either a positive or detrimental way.
Many questions are posed and debated over the course of the module, aided by video consultations, exploration of the literature, and observation of both orthodox and complementary therapies at work. Should doctors be aware of the effect of the mind-body interaction on human healing? How can they tap into this interaction to benefit the patient? Are they in danger of perpetuating the ignorance of the published literature on this subject, which so obviously persists in many branches of medicine even today? Should they be studying the placebo effect more closely so as to determine how to use it to aid their practice, instead of writing it off as an unwanted artefact?
The evaluation report concluded that we had identified areas central to the art of good doctoring, which seem not to be addressed directly by the mainstream medical curriculum for undergraduates. Such a conclusion is concerning; as Owen states, “How will those who choose not to do [the module] compensate for the lost opportunities of education?” The core medical curriculum at Glasgow has already changed in response to this dilemma. Based on the conclusions of the evaluation report, the undergraduate teaching from Glasgow's department of general practice now encourages more personal reflection and focuses more directly on the consultation, including those factors that influence its outcome.
Many challenges still exist, both for our own attitudes as students and for the undergraduate medical curriculum. We must focus on the bigger picture—producing student doctors who are aware of the value of having an appreciation of the art involved in medicine as well as the science, and of the importance of being a human being as well as a doctor.
Competing interests: None declared.