Overall, we concluded that we elicited a broad range of student opinions about CAM. After each group, the lead facilitator (JS) and the research assistant (SP) noted the presence of comments representing skepticism, enthusiastic endorsement, and neutrality (open-mindedness). In addition, post-hoc review of the transcripts confirmed that opinions of students regarding the CAM curriculum spanned the spectrum from highly positive to skeptical in most groups. The views tended to be similar within preclinical and clinical student groups. We were able to achieve theoretical saturation (that is, repetition of themes) of the data in both preclinical and clinical years. Whenever student perceptions diverged consistently by year, these findings are reported separately.
CAM content in the curriculum - Both preclinical and clinical students reported curricular exposure to information about acupuncture, diet and exercise, herbal remedies, and spirituality (meditation and prayer). Art and music therapy and cupping were consistently mentioned in the pediatric clerkship, and moxibustion on the OB-Gyn clerkship. Students reported rare or no exposure to chiropractic, manipulation, energy therapies, massage, aryuveda, and homeopathic remedies. Predictably, clinical students mentioned exposure to a greater number of modalities.
Methods of presentation of CAM material - Almost all second and third year students mentioned a particular evidence-based lecture on the cardiovascular benefits of acupuncture and that acupuncture was integrated into physiology lectures. They were also aware of a CAM first year elective and of CAM being integrated into a required first year standardized patient interview. Students repeatedly mentioned integration of CAM topics on the family medicine third-year clerkship. Some students also mentioned a CAM website, a CAM interest group, and a CAM weekend conference. Efforts to include CAM on other required clerkships such as psychiatry, OB-Gyn, and medicine and other CAM-related lectures were infrequently mentioned.
Other sources for learning about CAM - All students frequently reported learning about CAM through personal experience from family (especially grandparents and parents) and also self-initiated personal experience and friends. Other less frequently mentioned sources of information included the media and CAM-related websites. Clinical students sometimes mentioned learning about CAM from patients. The large majority of students from all years had some or a fair amount of exposure/experience with CAM. “My parents are Korean so they do a lot of alternative medicine. They do all the acupuncture; they do all the herbal medicines.” (MS3) “I get acupuncture every once in awhile and that cupping thing. And I drink like this herbal tea…but it's really nasty-tasting.” (MS2)
Personal use of CAM - Both second year and third or fourth year students tended to mention having tried such CAM modalities as herbals/teas, massage, chiropractic, exercise, and various nutritional interventions. Occasionally students were personally familiar with cupping, homeopathic or Chinese medicine, acupuncture, yoga, and meditation. Students never mentioned going to healers, homeopathy, or energy healing. “My mom is Indian and has a million concoctions and she throws them in milk or something gross and I have to drink it. So I do that all the time.” (MS3) “I used to use prayer to stay healthy. Sometimes I do massage, I do chiropractic. I've also gone to the flax and fish oil guy.” (MS2)
Belief in CAM efficacy - Among second year students, the most widely endorsed response was that CAM efficacy is highly variable, depending on the situation, the individual, and the type of modality being considered. Acupuncture was generally perceived as selectively effective for some conditions. There was more ambivalence about herbals. A minority across all years felt CAM was not at all effective. The majority of students were open to being persuaded of efficacy, and many felt positive about certain practices (such as acupuncture), but not others. Those who were open often recounted strongly positive personal anecdotes. A few, however, had become more skeptical about CAM because they believed that CAM was ‘not research-based’. “We're all about statistics and p-values, and all that other stuff. In order to use it in a western society, any type of eastern whatever… any type of CAM, I think you have to standardize it to the system that we're used to. Otherwise it's not really going to be valid” (MS2).
Clinical students expressed a wide range of opinion in terms of perceived efficacy of CAM. Some students adopted the position that if people believed in it, it generally does some good. Some argued that what we consider CAM is equal to western medicine but has not been validated by western norms. However, on the negative side, students expressed the concern that CAM is not necessarily benign, but we know very little about it. These students worried that people use CAM uncritically and that much more evidence is needed. “I don't know whether if it's actually the treatment that helps or just the placebo effect. But I think it's helpful.” (MS2) “I think what happens is that it works so well for some people, it becomes evidence to other people that it works. Where really it's not evidence, it's a story.” (MS2)
What constitutes evidence of efficacy - Discussing the issue of efficacy led us to ask about what kind of “evidence” was convincing to students. In the second year, there were some hard-liners: “If it's EBM-proven, then it transforms into real medicine.” Others put stock in “3,000 years of history,” for example, in the case of Chinese medicine. Testimonials of individual patients or friends and family seemed very compelling to preclinical students. They also expressed the view that patients “don't need” evidence if CAM is part of their culture. Some students were also willing to accept the “placebo effect” if the product had a positive outcome for the patient: “..…if it is something that's already in place in a patient's environment, you don't really need the evidence.” (MS2) “If (sic) this is the stuff they always do, and they're positive about it, I think that that makes it work better for them.” (MS3) “I think just for the placebo effect, it's very effective.” (MS3) “So you hear stories like that and it's really powerful, more so than any trial or study could be.” (MS3)
Among third and fourth year students, many, especially 4th year students, wanted “proof”, defined as clinical trials. This need for evidence was much stronger than among the second years. A few accepted the “proof” of historicity; another handful was influenced by personal anecdote. Some students suggested that, as an academic community, we need to be more open to creative ways of assessing efficacy other than the randomized clinical trial. On the whole, while open to the potential efficacy of CAM, these students were frustrated that there is not a lot of research being conducted and were focused on the potential risk of harm to patients in the absence of evidence. “We're not an alternative, a naturopathic school. We can't just talk… the way it's presented needs to be in a scientific manner … the way it's presented is too touchy-feely for me. It's too, ‘This is wonderful.”… where is the evidence?” (MS3) “…if I want to believe in something there has to be good evidence-based, statistical significance to what people are using…” (MS3)
Several students in both preclinical and clinical groups, although more so in the second year groups, discussed that evidence-based medicine (EBM) as a gold standard for efficacy might have limitations. Some regarded EBM as Truth with a capital t, but others recognized it as a culture-bound phenomenon. Third and fourth years were more intent on “wanting to know the science” behind CAM if it is presented in the curriculum (its mechanisms of action, pathways, EBM-proven efficacy). “…if you can incorporate CAM… and have those numbers to back it up, have some kind of evidence, because it's one thing to just say, ‘Well, I've heard that there's something called this, people take it when they're experiencing this’ but if you can back that up with numbers, it speaks a lot more…” (MS2)
Goals of CAM curriculum - Most students felt that the primary goal of the curriculum was awareness, to make students aware of CAM's existence: “It's out there and your patient might use it.” Both preclinical and clinical students frequently mentioned that the purpose of the curriculum was simply to get them to ask their patients about CAM: “…you need to be able to recognize that it exists and to be able to ask about it.” (MS3)
A smaller number of students mentioned goals of relating to patients using CAM practices with sensitivity and respect, transmission of (very limited) knowledge about CAM, influencing attitudes in a positive direction, and giving students tools to learn more. Particularly in the clinical years, students emphasized that the goal was not to learn to practice CAM or to know about all modalities. “The goal is to increase awareness of the treatments patients might be using. Awareness includes acceptance. Be wary of potential harms of CAM and also aware of the benefits.” (MS3)
A handful of students in both preclinical and clinical years had a skeptical view of the curriculum goals, labeling it as “just going through the motions” with “no real commitment”. These students wanted a more rigorous, in-depth curriculum. On the other hand, several students expressed the view that allopathic schools should not be in the business of educating doctors to “practice” CAM and that most allopathic physicians don't want to be “CAM practitioners.”
Attitudes toward CAM - Some students perceived one of the goals of the CAM curriculum to be improving students’ attitudes toward CAM. However, the majority believed CAM was presented in an “objective,” “scientific” way, not leaning toward either excessive endorsement or negativity, and they liked this approach. Fourth years were more likely than students in other years to say that participating in the curriculum made them feel more comfortable with CAM and about recommending it to their patients.
Least useful aspects of CAM curriculum - Opinions were divided among second year students, with some stating lectures were not memorable, while others thought lectures presented useful, “scientific” information. A standardized patient interview integrating CAM was judged by some students as too challenging and insufficiently educational, while others thought it served its purpose of preparing students for patients who use CAM. Exercises to interview and then discuss actual patients using CAM were also evaluated as not useful because of the difficulty in finding such patients. Preclinical students also requested more hands-on exposure: “I think you always learn a little bit more when you do something that's more interactive, more hands on. I would have liked to have more of an experience with various types of alternative medicine.” (MS2)
Clinical students complained that the curriculum provided inadequate understanding of what herbal remedies are for and how each one is used; “diet and exercise” prescriptions were encouraged without any meaningful understanding of nutrition or how to effectively counsel about weight loss; reflective discussion groups often seemed redundant; material was superficial and not well connected to clinical practice; written assignments seemed like busywork; and the curriculum overall was repetitive. A few clinical students noted that there was a prevalent feeling among most (other) students that CAM was just a “nuisance.” Overall, students preferred cases and demonstrations to lectures. “I feel like there's a discontinuity between teaching us what it is versus us actually being able to help our patients achieve what they want with it.” (MS3) “They let me go in and watch when they were doing it and the guy that was doing it explained it to me what he was doing and why and that was really helpful.” (MS2) “I think I learned what but I didn't learn how to transition that into practicing it or utilizing it in a practice setting.” (MS3)
Most useful aspects of CAM curriculum - Students mentioned experiential aspects and direct exposure, as well as certain reading materials and lectures. A few students noted that the mere presence of CAM in the curriculum was useful because it sent an important message about its relevance in medical education. Fourth year students were more likely than any other year of students to do their own PubMed or other database searches.
Suggestions for improving CAM curriculum - The most commonly mentioned suggestion among second year students was the need for a systematic overview of CAM information. Specifically, they wanted a single lecture providing a comprehensive overview of common (top 10) CAM practices, including definitions, examples, illustrative pictures, an identification of the most common uses of these practices, RCT-evidence of efficacy, and information about dangerous drug interactions and general harm: “..it would be more beneficial to me if I know what were the top ten supplements, the top ten maneuvers, and really more of the efficacy.” (MS3) However, a few students dissented, pointing out that “top 10” might vary from community to community or simply change, and argued that the curriculum shouldn't focus so much on content as on skills (how to search, for example).
By contrast, students in the clinical years stressed getting more practical training, including hands-on training, linking content information to clinical practice, and expanding field trips and community experiences that included observation of and interaction with practitioners and patients. They also suggested more training in how to integrate CAM with western medicine and specifically how to advise patients. Some students would have preferred more “useful” CAM, such as in-depth nutritional education as opposed to “far-out” CAM like aryuvedic because physicians make recommendations about these with most patients without being able to say more than “watch your diet,” or “get more exercise.” Many students also advocated for better content and better quality, not just “random smattering of very cursory lectures,” and a more useful and more efficient curriculum. Often, this seemed to be more teaching from scientific perspective, citing studies and evidence.
Other suggestions included a CAM Day to expose students in an experiential way, CAM “tag-alongs”, list of community CAM resources, panels of patients and practitioners, opportunities to do research, and incorporating CAM into existing EBM assignments. Most of these ideas came from second year students.
Structure of CAM curriculum - Required vs. elective: Students across all four years were reluctant to endorse more required CAM curriculum; most also did not see the need for additional electives, although a few did; a few thought it would be nice to have more optional CAM experiences. Among second year students, there was some sentiment that CAM should not be required at all because of resistance among their peers to attending lectures for any material not included on the US Medical Licensing Examination: “…we all focus on passing the boards. And anything that's not the exam… we don't really care about. It's so sad.” (MS2)
Placement in curriculum - Second year students sometimes suggested that CAM be required in 3rd year so long as it didn't supplant anything “more important”. Clinical students tended to say their years were already too full for more CAM, but agreed that the 3rd/4th years were the best place for CAM because of the greater potential for clinical applications. Both preclinical and clinical students agreed CAM should be present in 1st year, but in a very limited way, perhaps as one overview lecture; in the 2nd year, it could be linked to specific diseases and conditions. In the clinical years, the large majority of CAM curriculum occurred during the family medicine clerkship, and students agreed this was an ideal placement for the material.
Curricular integration - Students in both groups expressed the opinion that integration of CAM material in existing courses like Pharmacology, Topics in Medicine, Pathophysiology, and Biochemistry was desirable. Students wanted continuity and consistency: if they receive EBM validation of palmetto's efficacy in a family medicine CAM presentation, they would like the urologist on their urology rotation to be familiar with its use as well. Students differed about the extent to which such integration already existed. Students in the 3rd and 4th years emphasized that there wouldn't be so much resistance if CAM were presented as part of traditional courses, whether basic science curriculum or clinical clerkships.
CAM instructors - Second year students were divided between thinking physicians with CAM expertise would make the best teachers versus actual CAM practitioners. Clinical students tended to favor physicians who knew about CAM. They were skeptical of both CAM practitioners and patient testimonials.
Examinations and written assignments in CAM curriculum - The majority of students agreed that CAM was hard to test. Many believed that CAM should not be tested at all or that it should not be tested unless it could be presented factually. Most clinical students expressed a favorable opinion about CAM testing in an OSCE format. Written assignments about CAM were regarded with even less favor than testing.
Intentions to use CAM in students’ own practice - Most second year students were open to the idea of making CAM-related referrals, but most did not intend to practice CAM themselves. Several students stated that they wouldn't recommend CAM as first line treatment, but they wouldn't object to their patients using a CAM modality so long as it wasn't harmful. A minority of students took the position that they would not use CAM in any way unless they learned more about it, especially from an evidence-based perspective. A handful of students intended to incorporate CAM into their practices: “I may not personally do acupuncture on my patients but if somebody wants to talk about it, I'll talk about it, and I will probably recommend vitamins and supplements. It's pretty much guaranteed that I'm going to involve nutrition, exercise, and spirituality.” (MS2) “…I won't tell them not to do it. As long as there's no harm to them from the herbal (sic) medication.” (MS3).
Clinical students expressed more reservations. On the whole, they were willing to learn more about CAM, but they wanted to see EBM evidence about benefit and harm, otherwise they would not recommend it. They frequently mentioned wanting “proof.” Others were concerned that CAM could be exploitive of patients in terms of unnecessary expenditures and even outright quackery. Similar to second year students, even students who were open to CAM stressed it should be seen as supplementary, not alternative: western medicine should be tried first and only if it didn't work should patients then turn to CAM.
The majority of clinical students assumed a reactive position regarding the role of CAM in their future practices: if patients want to use it and if there's no harm, they wouldn't recommend against it. A handful of students anticipated a more proactive role in relation to CAM, describing multidisciplinary practices that would incorporate an acupuncturist, naturopath, nutritionist, and massage. Overall the most common attitude was one of limited openness to some level of incorporation. They favored the idea of CAM presence in their practices in principle, but didn't feel they knew enough to take more than a passive stance regarding usage: “As long as I know it's safe, it won't hurt them; it's a natural product, that's fine. If it works or not, we'll leave it up to them.” (MS3)