The Effect of Experiential Education on Students' Attitudes About Complementary & Alternative Medicine Practices

OBJECTIVES: To evaluate the effectiveness of an experiential Complementary and Alternative Medicine (CAM) education session in changing medical students’ beliefs, attitudes, and comfort level with CAM. DESIGN: Students attended a 3 hour class on Mindfulness Based Stress Reduction with a trained provider, and completed a Likert scale survey of their agreement with various statements about CAM both preand post-session. ASSESSMENT: Changes in agreement with 7 of the 10 items reached statistical significance, including increase in students’ subjective level of knowledge about CAM, decrease in the belief that CAM is too controversial to discuss with patients, increase in perceived ability to find information about CAM, and increase in support for the inclusion of CAM in the medical school curriculum. CONCLUSION: A CAM experiential session was effective in changing students’ beliefs and attitudes, and improved their comfort levels with CAM. Similar sessions could be a valuable addition to the medical school curriculum. Background As defined by the World Health Organization, complementary and alternative medicine (CAM) is “a broad set of health-care practices that are not part of a country’s own tradition and not integrated into the dominant health care system. Other terms sometimes used to describe these health care practices include ‘natural medicine’, ‘nonconventional medicine’ and ‘holistic medicine. ’” (Bulletin of the World Health Organization, 2004) It is well recognized by practitioners and medical educators that the use of complementary and alternative therapies in the United States has continually increased over recent decades. Epidemiologic studies have shown that the lifetime prevalence of CAM therapy use in the United States has increased steadily since the 1950s (Kessler et al., 2001). In a UNM study assessing the frequency of CAM use, 90.2% of the 612 participants reported using CAM to treat their diagnosis of arthritis (Herman et al., 2004). A recent study of patients in primary care settings in West Texas reported that over half of the study participants used some type of CAM, and, of note in our current economic recession, CAM use was inversely correlated with the ability to get a timely appointment with a healthcare provider, or to access healthcare resources (Zhang, 2008). As many as 70% of patients do not reveal their use of herbal remedies to their allopathic health care providers (Miller, 1998). Frenkel showed that patients tended to anticipate a negative response from the physician if they were to reveal their CAM use, and they often sensed that their physician was not interested in or able to contribute useful information about CAM. This anticipated negative response and perceived lack of knowledge leads patients to believe that their use of CAM is not relevant to the conventional treatment they receive, and causes them not to voluntarily disclose this aspect of their medical history to their physician (Frenkel, 2001). The withholding of information about CAM usage from allopathic medical providers can be deleterious to patient health. Reports of adverse reactions to CAM have more than doubled in three years (Bulletin of the World Health Organization, 2004). This statistic underscores the need for physicians to be knowledgeable about CAM practices, as they are not only widespread, but can have a serious impact on the overall health of their patient population. Various biological compounds used in CAM therapies can cause abnormal lab results or potentially interfere with the metabolism of medications. When patients fail to report their use of such compounds, it can lead practitioners to misinterpret test results or misjudge the efficacy of a particular therapy. An example of the impact of this confusion is apparent in mainstream medical struggles with the popularity of traditional Chinese herbs among cancer patients. Chiu et al (2008) have gone so far as to publish specific guidelines in an oncology journal to enable those who work with cancer patients to anticipate potential drug interactions and to counsel patients appropriately. While undoubtedly helpful, this publication is an example of addressing a problem in retrospect that needs to be faced head-on. While it is not realistic to expect physicians to become experts on all aspects of CAM, formal introduction to a variety of CAM therapies during medical school could help physicians-in-training to be aware of potential areas of overlap between CAM and other medical modalities and to anticipate problems that could arise. As patients more frequently use CAM and consult CAM practitioners for disease prevention, treatment, and health promotion, there is a strong need to develop proper educational and training modules for clinicians. As long as there remains a lack of formal medical training in CAM at either the undergraduate or professional level, physicians are left to their own resources in order to support such a dialogue with patients. Many doctors acknowledge they are not confident to discuss CAM with their patients, and that they feel the need for further education and training in this field (Fearon, 2002). Overall, doctors are at the same time accepting of their patients’ use of CAM, would like to participate in CAM continuing education, and support for medical school education in CAM (Hall, 2003). 61% of physicians in one survey reported discouraging CAM therapies because they are not knowledgeable enough about the safety or efficacy of CAM treatments, but 81% of the same group claimed to want more CAM education (Milden, 2004). Currently, scant literature exists exploring the effectiveness of CAM education in a medical school setting. Indeed, it appears that traditional medical training has the effect of increasing students’ skepticism about CAM practices, and decreases their interest in learning more about CAM modalities (Furnham, 2003). However, after integrating evidence-based information on CAM treatments into a pharmacy school curriculum via lectures and clinical case studies, the faculty at the school found that students’ selfassessed and actual knowledge about CAM practices increased, that the training did not interfere with learning the material in the traditional pharmacy curriculum, and that students wished they had begun receiving such training earlier in their schooling (Tiralongo, 2008). The success of this program suggests that science-based medical training and CAM education need not be antagonistic. This suggestion is also supported by medical student response to a curriculum at Texas A&M University integrating evidence-based medicine training and information about CAM. 98% of students reported that training in CAM would be useful in their future work, and there was a significant increase in the students’ view of the appropriateness of integrating CAM training into the traditional medical school curriculum (Forjuoh, 2003). In 1994, Borkan et al. demonstrated that physicians who use CAM for themselves or their families had a higher rate of patient referrals for CAM therapy, demonstrating that experience with CAM may increase familiarity about and comfort with its usage among doctors. Based on this information, our research project was designed to explore whether an experience with a CAM modality would similarly impact the attitudes of medical students with regard to feeling more comfortable discussing CAM therapies with patients, and to explore an experience-based avenue of CAM education among medical professionals in training. The specific modality we explored was Mindfulness-Based Stress Reduction (MBSR), a method pioneered by Dr. Jon Kabat-Zinn that has been reported to be successful in the treatment of chronic pain, anxiety and panic, and other medical diagnoses (Kabat-Zinn, 1993). Our focus was not to look at the efficacy of this method as a treatment modality, but instead to explore the impact of an experience in MBSR on medical student attitudes, beliefs, and comfort level with CAM as a means of assessing the effectiveness of experiential education in CAM as an addition to the medical school curriculum. Methods Our subjects were students enrolled and in good academic standing at the University of New Mexico pursuing a doctorate of medicine degree. No other requirements were necessary for enrollment. Subjects were recruited through announcements made during breaks between lectures to first and second year medical students. Subjects signed up at that time to receive more information about the project. All students who signed up received an email detailing the time, place, and content of the MBSR class. 18 students committed to attend. Subjects were not offered any monetary compensation for their participation, nor were there any penalties for not participating. The MBSR session was conducted at the Center for Life, an off-site integrative medicine facility, associated with the University of New Mexico. On the night of the session, students were given a consent form and informed of all potential risks and benefits. All 18 subjects consented to participate and signed forms at that time. They were then administered a pre-class survey (Appendix A) using a Likert scale to report their beliefs and attitudes about CAM. The survey had been approved by the UNM HRRC and was previously validated in a study of opinions and attitudes of physicians in the community. The class was lead by a practitioner formally trained in MBSR and used techniques typical to classes in MBSR. Although MBSR is traditionally conducted in a 68 week session, with 2-3 hours a week, due to time constraints with medical student schedules, we developed a brief, one-time 3 hour session consisting of basic principles and exercises of MBSR. After the class, students were asked to fill out the same survey. No identifying information was requested or listed on either form. The preand postsurveys were linked by a randomly assigned number and the letter “a” or “b”