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Despite recommendations that complementary and alternative medicine (CAM) familiarization should be offered to UK medical students, in Wales little such teaching was offered. We decided to assess medical students’ knowledge of CAMs, perceived training needs in CAMs, their view of its role in the National Health Service (NHS) and current teaching given. Analysis of data from a questionnaire given to medical students and direct questioning of senior academic medical school staff in Cardiff and Swansea Medical Schools was carried out. The participants comprised 78 first year medical students in the undergraduate entry program in Cardiff and 58 first year medical students from the graduate entry program in Swansea. Senior academic medical school staff at Cardiff and Swansea Medical Schools were asked about current CAM teaching. Results revealed that 32% of undergraduate entry students (UGES) had previous knowledge of CAMs compared with 51% of graduate entry students (GES). Of the UGES, 62% believed they should be taught about CAM's compared with 94% of GES. Of UGES 31% felt that CAMs have a role in the NHS compared with 50% of GES. None of the students had received teaching about CAMs and little formal CAM teaching is currently included in the curricula at each site. The majority of medical students in Wales would like to receive CAM teaching and significant numbers support a role for CAMs in the NHS. Little formal teaching is currently provided.
In ‘Tomorrows Doctors’ published in 2003, the General Medical Council (GMC) stated that students must be aware that many patients are interested in and choose to use a range of alternative and complementary therapies. Graduates must be aware of the existence and range of such therapies, why some patients use them, and how these might affect other types of treatment that patients are receiving (1). The British Medical Association (BMA) also recognized the need for teaching of complementary and alternative medicines (CAMs) in medical schools (2) and government concern about the increased use and relative lack of regulation of CAMs led to an investigation of CAMs by the House of Lords Select Committee (3). The Select Committee report, which was published in 2000, made recommendations concerning the teaching of CAMs to healthcare staff including medical students and doctors. These recommendations included:
The House of Lords Select Committee commented on CAM teaching at a number of UK Medical Schools including University of Wales College of Medicine UWCM, now Cardiff University Medical School. At Cardiff it was noted, ‘that little or no teaching is devoted to complementary medicine, though a Special Study Module in this subject is offered’ (3).
The recommendations made by this committee were fully endorsed by the government in its response in March 2001 (4) and the Royal College of Physicians set up a Complementary and Alternative Medicine Committee, which held its first meeting in London in October 2001.
In May 2006 a letter was sent by a group of doctors headed by Michael Baum, Emeritus Professor of Surgery at University College of London, to the chief executives of UK National Health Service (NHS) Trusts. The group suggested that NHS trusts should not pay for CAMs and subsequent public debate included support for CAMs by the Prince of Wales (5).
The above led us to seek the views of first year medical students attending medical schools in Wales. Our aim was to seek their current knowledge on CAMs, perceived teaching needs, what role they felt CAMs may have in the NHS and what CAM teaching was currently provided.
A voluntary questionnaire (Fig. 1) concerning various aspects of CAMs was distributed to 80 of 300 first year undergraduate entry students (UGES) who were attending a compulsory dissection class in October 2006 at Cardiff University Medical School. Students were selected because they were assigned to library tasks rather than actual dissection, making completion of the questionnaires easier. Similarly, questionnaires were also handed out to all 65 of 71 first year graduate entry medical students (GES) who attended a compulsory clinical conference at Swansea Medical School in November 2006. In order to compare like with like, Cardiff students in the undergraduate intake who had previous degrees were added to their peer group in the Swansea graduate entry intake. The data was then collated to see if there were differences between the UGES and GES groups and if there were any gender related differences between the men and women in the combined groups.
Seventy-eight of 80 questionnaires given to the Cardiff undergraduate entry medical students were returned; four students had previous degrees and were added to the Swansea graduate entry medical student group. Fifty-eight of 65 questionnaires were returned by the GES group. After reallocating the four Cardiff graduate students there were 74 in the UGES group and 62 in the GES group. Twenty-two students in the UGES group and 17 in the GES did not state their age. The mean age of 52 of 74 students in the UGES group was 18.5 years [range (18—23 years)]. Similarly, the mean age of 45 of 62 students in the GES group was 24.6 years [range (21–37 years)]. There were 51 (69%) women in the UGES group compared with 26 (42%) women in the GES group.
To assess current teaching provisions for CAMs, we approached senior academic medical school staff at each site.
Of the 74 UGES, twenty-four students (32%) comprising nine men and 15 women said they had knowledge on CAMs but only 7, (9.4%), one man and six women had personally experienced CAMs. Similarly, of the 62 GES, 32(51%), 17 men and 15 women had knowledge on CAMs and 18(29%), five men and 13 women, had personally experienced CAMs. This difference is statistically significant (P<0.001).
Of the UGES, 62% (15 men and 31 women) believed that medical students should have a basic knowledge of CAMs. Of the GES group 94% (33 men and 25 women) felt that teaching medical students CAMs was necessary. The difference between the groups is statistically significant, P<0.001.
Of 136 students only 42 responded so the results were collated for the combined group. CAMs that were considered important were acupuncture 27/42(64%), herbal medicine 16/42(38%), chiropractic 13/42(31%), osteopathy 11/42(26%), homeopathy 5/42(12%) and reflexology and Tai Chi 3/42(7%) each. Aromatherapy was not mentioned.
Of UGES, 23/74 (31%) felt that CAMs had a role in the NHS, 30 (41%) did not know and 21 (28%) said no. This compared with 31 (50%) of GES who believed CAMs had a role, 21 (34%) who did not know and 10 (16%) said no. The difference between the two groups is statistically significant (P-value <0.005).
No student from either the UGES or GES groups had received or been offered any CAMs training.
Within the combined GES and UGES there were no statistically significant gender differences for perceived knowledge of CAMs, the role of CAMs in the NHS and need for teaching on the subject. However, there was a difference between males and females personal use of CAMs. Of the women, 31% had used CAMS compared with 9% of men.
In both Cardiff and Swansea, senior academic staff noted that little formal CAM familiarization was provided within the core curriculum.
In our study, the GES had more personal experience and knowledge on CAMs than the younger UGES group. There was a gender difference in personal CAM use overall with female students more likely to have personally experienced CAMs. In a similar study to ours in 1999, first year medical students in the UK were asked to rate CAM therapies following a core teaching session. In agreement with our findings, it was found that female students had used CAMs more than their male colleagues. However, there was no significant gender difference regarding their rating of the therapies after a core teaching session (6). Our results largely agree with this and we believe that the differences seen in our UGES and GES are almost certainly due to age differences and related life experience. The differences may also be related to the subjects of GES first degrees but this data was not collected.
Most of our students said they should have a basic knowledge on CAMs with an impressive 94% of the GES group wanting CAM familiarization. Fewer of the UGES (62%) felt they needed CAM education but this could be because the UGES had less personal experience in the area. In agreement with our results several studies have shown that medical students are interested in learning about CAMs (2,7–14) and one study showed that 69% of students believe that alternative practitioners can provide effective treatment (7). Such familiarization is important because CAMs are widely available in UK hospitals (15) and many patients use CAMs. A study, which investigated the use of CAMs in dermatology patients revealed that half of over 400 patients attending the dermatology departments in Cardiff and Swansea were using CAMs to treat their skin problems. The most popular therapies were homeopathy and herbal medicine (16). It is likely that patients attending other specialist clinics may also be using CAMs, some of which could have adverse effects such as drug interactions with St Johns Wort, allergic reactions with tea tree oil and rarities such as prepubertal gynecomastia linked with essential oils (16–19). This is supported by a study from North East Scotland concerning CAM use by local residents, which revealed increased usage of aromatherapy, acupuncture and reflexology over the study period of 1993–1999 (20). Furthermore, serious medical conditions may be alleviated by CAMs and a recent review of cardiovascular disease in The Lancet discussed the role of stress in its etiology (21). Many CAMs have been shown to be effective in stress reduction (22) so, we feel it is important that healthcare workers have a knowledge on both allopathic and CAM approaches to stress management. Therefore, we endorse the view that medical students, doctors and other healthcare workers should have a working knowledge on CAMs and of their possible benefits and side effects.
Our results showed that our students were interested in learning about acupuncture, herbal medicine, chiropractic, osteopathy and homeopathy but curiously, not aromatherapy, which was popular with other students and patients (6,16). Greenfield et al. (6) asked first year medical students, which CAM therapies they wished to study. The most popular treatments were chiropractic, hypnotherapy, aromatherapy and acupuncture. Clearly all these CAMs should be included in any proposed famliarization course but of greater importance is familiarization with CAMs most commonly actually used by patients.
A significant proportion of our students felt that CAMs should have a role in the NHS and though many were undecided, relatively few felt that CAMs should be excluded. We feel that patient demand may eventually lead to increased use of CAMs within the NHS. In a combined study of over 700 patients attending dermatology outpatients in Leeds, Swansea and Cardiff, 75% felt that CAMs should be available within the NHS and 88% felt they should be considered alongside conventional medicine (16). Unfortunately, the NHS does not have infinite resources, so cost is a major consideration when new services are proposed. Britons currently spend £130 million a year on complementary treatments (23) and it is unlikely that the NHS could support all CAMs but perhaps some may be integrated. Already CAMs, including reflexology, aromatherapy and reiki are widely used in palliative care and oncology services and in some trusts acupuncture is used for pain relief (15,24). One study showed an increase in pain free days in patients who underwent acupuncture for pain related to osteoarthritis of the knees and reported a reduction in the number of days’ pain medication was required (25). Therefore, it may be that the introduction of some CAMs, such as acupuncture would lead to lower drug bills thus making the treatment more financially appealing.
None of our students had received any CAM familiarization, though they were only in their first year of training. However, from the responses from academic staff at each site little formal CAM teaching is currently provided on either course. This is at odds with the recommendations for undergraduate training given by the GMC in Tomorrow's Doctors (1). The BMA also recommends that medical students should be provided with awareness education about CAMs during their undergraduate studies (26) and a survey by Morgan et al. (10) 1998, indicated that an increase in CAM information provided to undergraduate doctors is needed if they are to meet the increasing requests by patients for guidance on CAMs. Medical schools in Wales do not yet appear to have addressed this issue and we agree with Rampes et al. (9) who, finding that medical students would like more education on complementary medicine, suggested that ‘a national core syllabus on complementary medicine be devised in consultation with organizations that teach complementary medicine to registered health professionals’. We agree with this suggestion, which would ensure that appropriate CAM teaching was available throughout the UK.
Arguments for and against the provision of CAMs within the NHS remain a political and medical issue and the suggestion that the National Institute for Health and Clinical Excellence should evaluate CAMs has been recently debated (27,28). Some familiarization with CAMs for medical students and doctors is less controversial and was the view stated in the House of Lords Select Committee's Report on CAMs in 2000. However in Wales, 6 years after this report, and despite endorsement from the GMC and BMA, the medical student curricula are still not offering such familiarization. Our survey conclusively shows that our medical students wish to learn about CAMs and, in particular, postgraduate entry students recognize the need for such education. We feel that little progress will be made unless a national core syllabus on CAMs is developed and appropriate legislation introduced.
We thank Dr George Lewith, Reader in Complementary Medicine, University of Southampton for his help in the questionnaire design and editorial comments and Jonathan Barlow BSc, Cardiff University Medical School for help with statistical analysis of the data.