In reviewing our survey findings, we were encouraged to note that the majority of incoming students at both NESA and OCOM expressed interest in learning about and participating in research. This was also somewhat surprising as historically, like many CAM users,11,12
AOM/CAM practitioners often state they were attracted to CAM because it represents an alternative health paradigm to the research-based biomedical model. The relatively high level of interest in research we observed among incoming AOM students may reflect the fact that NESA and OCOM, as research-invested institutions, attract research-minded applicants. Interest in research may also be a reflection of the increasing numbers of students entering both AOM schools from undergraduate schools where they have had research-infused pre-med training (unpublished demographic data from NESA and OCOM).
Yet, despite this high level of interest in research training and participation among first year students, research interest was lower among students enrolled in later years of both programs. Because our data were collected as a cross-sectional survey, we cannot assume that trends across years necessarily reflect changes in cohort’s attitudes as they progress through the curriculum. However, if we assume these between-year results would hold for within-class longitudinal results, this would suggest an effect of education as students mature into clinicians. From the second year onwards in both programs, students devote an increasing amount of time to developing clinical skills and seeing patients, and thus their growing clinical interests may compete with and overshadow their initial enthusiasm and time for research. This tension between interests in clinic- and research-related activities is well known in conventional medical training, and partially underlies the widely reported difficulty of sustaining large numbers of clinician-researchers.13,14
Yet the true impact of education will only be known through longitudinal follow-up. Another possibility is that difference in interest in research between classes is related to differences in class characteristics (cohort effect) as opposed to education over time. We do see some demographic differences (gender, education) which may lend support to this theory. Nevertheless, even with the lower ratings seen in years 2 and 3 of both programs, approximately 40–50% of third-year AOM students still expressed interest in learning about and/or participating in research. With further development and administration of research training initiatives at both institutions, we anticipate that the initial interest in research may be sustained at a higher level.
A second interesting result of our survey is the striking difference in students’ beliefs in the relevance of research to those outside the profession versus those practicing within it. Students nearly unanimously agreed that research would improve public perception of acupuncture, and would positively impact insurance coverage for acupuncture treatment. In contrast, and especially for NESA students, there was markedly less support for the statements suggesting that research will inform clinical practice. These responses may be related to belief about the consistency of the scientific method with AOM principles, which was rated on average very low. Over time, we expect a greater proportion of students at NESA and OCOM to believe that well designed research is not incongruous with AOM, and that research, and knowledge of this research, can inform clinical practice.
Limitations of the study
While survey results from the two AOM institutions showed marked similarities, it is important to emphasize a number of limitations of this study. First, while the survey questions we evaluated were administered at two independent AOM schools, the generalizability of the observations to other AOM schools may be limited. NESA and OCOM are two AOM schools with a long-standing commitment to research and research education, and thus students attracted to and attending these institutions may not share research-related values with students at other AOM and CAM institutions less committed to research.
Second, the instruments used at both institutions have not yet been evaluated for validity and reliability, and thus may be biased.15
Additionally, there are important differences in the format of questions used in surveys at both institutions. For example, level of agreement to most questions at OCOM was assessed with an affirmative statement, while at NESA, it was assessed by degree of interest. While such differences in format could technically bias comparisons between institutions, the remarkable parallel in responses between institutions suggests this was unlikely. Finally, one questions (#7) was negatively worded, and it is possible that this phrasing impacted responses.
Third, the results presented reflect only one point in time. They were collected to serve as a baseline for ongoing evaluation of research-related values and, more broadly, to assess the impact of initiatives to encourage research literacy and participation. As such, it is important not to over interpret trends across cohorts within an institution as longitudinal changes in attitudes within a cohort. Repeated administration of validated versions of our surveys will address and remedy the above issues.
However, despite the preliminary nature of our results, the survey questions included in this paper address timely and relevant issues regarding the goals and value of research training at CAM schools. To our knowledge, these issues have not been systematically explored at CAM institutions. We hope that this preliminary publication of our results stimulates other CAM institutions to conduct parallel evaluations. This would enable comparisons regarding research interests to be made, and inferences to be drawn, from a much larger and diverse set of CAM institutions.
Implications for evidence based healthcare and research education
It is increasingly believed that CAM practices such as AOM must be based on sound clinical and basic research and be practiced in an evidence-based manner if they are to contribute to the future of health care. This is especially the case in settings where CAM therapies are integrated with conventional medicine.16–18
It has also been argued that CAM research requires the active collaboration of experienced CAM practitioners.2,4,19,20
Knowledgeable practitioners are needed not only to provide effective treatments in the context of clinical or mechanistic studies, but are needed to inform all aspects of research–– from study conception and identification of relevant hypotheses to development of treatment interventions, choosing outcomes measures, and interpreting results. For this to happen, there is a need to enhance research training in the curriculum of CAM institutions. This need has been recognized by NCCAM/NIH and is reflected in a number of innovative initiatives to build research literacy and research infrastructure at CAM institutions, including the DCRC and R25 grants awarded to NESA and OCOM, respectively.20,21
However, the relevance of research to CAM practitioners and CAM professions as a whole has been questioned by some within the field based on perceived limitations of widely used research designs to evaluate CAM efficacy and underlying mechanisms.22–25
For example, uncertainties regarding the inertness of sham needle controls, or the attempt in some trials to minimize patient-practitioner interaction bring into question whether these methods grossly bias the intervention being evaluated and lead to artificially reduced effects sizes. Additionally, resistance to research may result from the association of research with more mainstream and reductionist medicine as a whole, and the political desires of some practitioners to maintain autonomy/independence from it. Surprisingly, few attempts have been made to systematically evaluate CAM practitioners’ perspectives on the value of research to their profession.26
To the best of our knowledge, this paper reflects the first attempt to directly and systematically assess AOM students’ perspectives on the potential value of integrating research education into their AOM training.
A central aim of NCCAM’s DCRC and R25 programs is to more fully engage CAM practitioners in research. Based on the results of this survey, and more broadly, on our experience developing research programs and research education initiatives at NESA and OCOM, we believe that it may be useful to classify general levels of research interest among our students into three broad categories. First, there is a large and growing number of students who appreciate that sound research is essential for the development of the AOM profession. Consequently, as eventual practitioners, they feel it is essential to develop AOM-relevant research literacy competencies, e.g., a basic knowledge of the principles of clinical and basic research, an ability to search for and evaluate AOM research findings, and an appreciation of issues unique to studying complex interventions such as AOM. These competencies will position them to communicate more effectively with both patients and conventional practitioners, and will inform some aspects of their clinical practice. Second, there is a small number of students, including those with prior research experience, who seek to include research as part of their careers. As clinician-researchers, they may choose to engage in research in a number of ways including collaboratively developing treatment protocols and providing treatments in clinical trials, helping in the overall design of studies, and contributing to evidence-based reviews of the literature. A smaller proportion of these clinician-researchers with appropriate levels of training might even serve as study principal investigators. Finally, we believe there will always be a third group of students who have minimal interest in research and believe it is largely irrelevant to their practice. A common view among this group of students is that, because some aspects of AOM are based on energy medicine (and more intuitive processes), the current emphasis on reductionist scientific methods is of little value for developing clinically relevant research. Right or wrong, we believe this voice adds important diversity to the student body and to the profession. Nevertheless, it is possible that as AOM research methodology develops, and more readily adopts experimental designs and interventions that more accurately reflect clinical practice (e.g. pragmatic clinical trials), and as these approaches are highlighted in research courses, the size of this third group of students may decrease.
With these distinctions in mind, NESA and OCOM’s research training programs are aimed predominantly at impacting the first two groups of students. Both AOM schools include required courses that provide training in basic research principles, as well as practical skills such as identifying, retrieving, reading, and evaluating original literature. For NESA students interested in additional training, research electives that teach more advanced research principles and skills are now offered.2
Additionally, a key component of more advanced research training at both institutions occurs via hands-on participation in clinical trials (e.g. research assistants), surveys and case series research, and the writing of peer-reviewed scientific papers. In conventional medicine, there is a well-established positive relationship between participation in research during medical school and post-graduate research.14,27
Finally, both NESA and OCOM have also developed parallel research training initiatives for faculty and staff.2,7
Initial outcomes from these faculty initiatives have been very positive, and are playing a central role in catalyzing the infusion of research into broad aspects of the curriculum as well as the culture of our AOM institutions.
This survey represent the first attempt to systematically assess AOM students’ perspectives on the potential value of integrating research education into their AOM training. Preliminary results suggest interest in research among AOM students is high, early on in training. Results also indicate that AOM students believe research is highly relevant to how both the public and the health insurance industry view their system of health care, but not highly relevant to their own clinical practice of AOM. Repeated implementation of validated versions of our surveys are needed to confirm the trends we report and to evaluate the impact of research training programs already in place on AOM students attitudes towards research.