Complementary and Integrative Health Education in the Medical School Curriculum: An Interest Survey

Abstract

Objective: The use of complementary and integrative health (CIH) modalities continues to increase; yet, there is limited instruction in these methods in undergraduate medical-school curricula. The objective of this research was to evaluate interest in developing a CIH curriculum at the Uniformed Services University of the Health Sciences (USUHS), in Bethesda, MD.

Materials and Methods: Students and faculty of the USUHS were emailed a 10-question online survey and responded via a Likert scale and open-ended questions.

Results: There was interest in learning more about CIH; 65% of student survey respondents and 61% of faculty survey respondents indicated that they “probably” or “definitely” believe that a curriculum in CIH should be instituted at the USUHS.

Conclusions: The addition of a curriculum in CIH would be beneficial to future patients who will benefit from the students' additional knowledge and experiences. This curriculum would also benefit the students who would be able to use their knowledge of CIH practices to relieve stress and mitigate burnout.

Introduction

Complementary and integrative health (CIH) encompasses a wide array of practices and products that have continued to increase in popularity over the past decade.¹ The goal of integrative health, also known as integrative medicine, is to achieve health through a holistic approach utilizing best practices in the realms of the body, mind, and spirit.² Integrative health brings together conventional Western medicine and practices outside the scope of Western medicine known as alternative or complementary, which are used by more than 30% of adults and 12% of children in the United States.^3,4 Often, these two terms are used synonymously; however, they have slightly different meanings. A nonmainstream practice used in place of conventional medicine is alternative, while a nonmainstream practice used alongside conventional medicine is complementary.³ This discussion uses CIH, because it is the term used by the National Center for Complementary and Integrative Health (NCCIH).

It is estimated that 59 million people above the age of 4 have had at least one complementary health expenditure.⁴ The 2012 National Health Interview Survey estimated that $30.2 billion was spent on out-of-pocket costs for CIH interventions in 2012 alone.⁴ The most common complementary health applications included natural products (i.e., herbs, vitamins, minerals, and probiotics) as well as deep breathing, yoga, t'ai chi or Qigong, chiropractic or osteopathic manipulation, meditation, massage, special diets, homeopathy, progressive relaxation, and guided imagery.³

CIH practices provide tools to prevent, treat, and manage a variety of conditions, including chronic pain, smoking, obesity, stress, and anxiety. The growing use among the American public, as well as the potential to help combat some of the nation's most pressing medical problems, make CIH an important subject for future physicians. In addition, medical students' education on, and utilization of, CIH practices have the potential to mitigate burnout, depression, and psychologic stress in the health professions.⁵

In the United States, 40% of medical schools have membership in the Academic Consortium for Integrative Medicine and Health,⁶ and 50.8% of medical schools offer at least one CIH course or clerkship.⁷ In a study of 266 preclinical (first- and second-year) students at Georgetown University School of Medicine, 91% of students agreed that Western medicine could benefit from CIH ideas and methods.⁸ Of these students, 85% felt that knowledge about CIH was important to them as future physicians and 75% felt it should be integrated into their medical curriculum.⁸ Undergraduate and graduate entry-program medical students who completed a survey at the Royal College of Surgeons in Ireland indicated that they believed that experience with integrative health was a vital component for their future careers; yet these students had not received enough education on the subject in medical school.⁹ In addition, students in a longitudinal study indicated that they thought that, if physicians had further education concerning their patients' beliefs and health behaviors, patient care could be improved.²

Currently, there are mandatory and elective integrative health curriculum components in place throughout the undergraduate medical education system. During the preclerkship organ system–based modules the USUHS School of Medicine^* curriculum exposes students to complementary and integrative topics including pain-management techniques, supplements, and nutrition. A CIH interest group holds discussions and demonstrations in complementary medicine throughout the clerkship and postclerkship period, with elective opportunities for student participation. Although there is exposure to complementary and integrative practices in the USUHS medical-education program, a more-structured approach would be beneficial. A survey was performed to assess beliefs and attitudes among USHUS students and faculty regarding CIH practices to gauge readiness for a formal curriculum in CIH.

Materials and Methods

The survey created had 10 questions concerning each individual's current knowledge, interest, and attitude about CIH practices; see Appendix 1 for the full survey. In November of 2017, the survey was e-mailed to all medical students in the classes of 2018–2021 and students of the USUHS Graduate School of Nursing (GSN) class of 2019 and 2020, as well as the faculty of the USUHS. Those surveyed responded via a mix of Likert-scale questions and open-ended queries to allow for further expansions or explanations for responses to certain questions. A total of 344 responses were received, which were then separated into a student pool and a faculty pool for comparison and for analysis by Fisher's exact test. The results were also combined to assess the overall attitude of the USUHS better with respect to CIH practices and the possibility of a structured CIH curriculum.

Results

The students responded to the survey at a rate of 6.7% (54/801); the total number of students was calculated by adding enrolled medical students (681), and the GSN classes of 2019 and 2020 (120). The faculty responded at a rate of 5.4% (290/5339); the total number of faculty was calculated by adding the School of Medicine faculty (4750), the GSN faculty (169), the dental faculty (411), and the College of Allied Health faculty (9). Due to unique curriculum at USUHS, there are ∼460 students and 500 faculty members on campus. The remaining students are away on clinical rotations, and the remaining faculty members are “National” faculty members who teach at various clinical sites throughout the country.

The current authors believe that the respondents were primarily students and faculty members who were on campus at the time of the study. There has been a historically low response rate of medical students who are away on clerkships. When subtracting the third- and fourth-year clerkship students (340) from the total student pool (801), and using the difference as the new denominator (461), the response rate for students went up to 11.7%. A clearer distinction was made among the faculty responses; 210/290 contained the .edu e-mail address used by on-campus faculty members. When the response rate was calculated using the on-campus faculty responses (i.e., from .edu addresses; 210) from the pool of 500, the faculty response rate went up to 42.0%.

These results demonstrated favorable attitudes toward CIH, a willingness to learn more about the topic, and the opinion that there should be integration of CIH practices in the USUHS School of Medicine and GSN curricula (Figs.1 and 2).

FIG. 1.

Current knowledge or experience with complimentary and integrative health. Color images available online at www.liebertpub.com/acu

FIG. 2.

Interest in learning more about complimentary and integrative health. Color images available online at www.liebertpub.com/acu

Among the student and faculty respondents, there was a very broad range of interest in complementary methods; some of the more popular responses included acupuncture, manipulation, meditation, massage, nutrition, supplements, and yoga. The faculty members who replied to the open-ended question were particularly interested in acupuncture (42.4%; 89/210), with substantial interest in meditation (33.3%; 70/210), and manipulation (21.0%, 44/210). The interests of the students who replied to that question was greater proportionally than the faculty in all of these topics, with 53.5% (23/43) listing an interest in acupuncture, 48.8% (21/43) listing an interest in mediation, and 41.9% (18/43) listing an interest in manipulation. There was overall agreement among the total responses for the use of CIH practices in modern medical treatment, and the vast majority (70%) indicated that a belief that they are effective for treating disease.

Students and faculty members who were unsure or not interested in learning more about CIH wanted to see personal examples of complementary health methods providing care effectively as well as a more robust body of randomized controlled trial research. In addition, the faculty members wanted to see specific applications to their medical specialties and adequate referral avenues. Among the respondents, 65% of the students and 61% of the faculty respondents believed that there should “probably” or “definitely” be a curriculum in place at the USUHS that focused on CIH (Fig. 3)

FIG. 3.

Interest in having a curriculum focused on complimentary and integrative health. Color images available online at www.liebertpub.com/acu

The majority of students and faculty members who responded indicated that they would also attend a forum to learn more about complementary health practices, with some respondents' decisions being contingent on applicability to their specialties in medicine or receiving continuing education credits. This question was the only one in which there was a significant difference (P = 0.03) in the responses between the students and the faculty members, most likely due to the fact that students are still generalists, unlike many of the faculty members who received the survey (Fig. 4 and Table 1).

FIG. 4.

Interest in attending a forum on topics in complimentary and integrative health. Color images available online at www.liebertpub.com/acu

Table 1.

Complimentary and Integrative Health Interest Survey Results

Question 1: What is your current knowledge or experience with Complementary and integrative Health practices?
	Student % (n)	Faculty % (n)
I have never heard of it	5% (3)	3% (10)
I have only heard of it	43% (23)	29% (81)
I have tried it	26% (14)	23% (65)
I use it occasionally	20% (11)	27% (75)
I use it routinely	6% (3)	18% (50)

Question 2: Would you be interested in learning more about Complementary and Integrative Health?
	Student % (n)	Faculty % (n)
No, I am not interested at all	4% (2)	3% (9)
I am uninterested	0% (0)	5% (13)
I'm neither interested nor uninterested	6% (3)	15% (42)
I am interested	58% (31)	50% (141)
I am very interested	32% (17)	27% (76)

Question 4: Do you think that Complementary and Integrative Health practices have a role in modern medical treatment?
	Student % (n)	Faculty % (n)
No, it is not beneficial at all	2% (1)	1% (4)
It is not very beneficial	2% (1)	4% (10)
I am undecided	15% (8)	12% (34)
It is somewhat beneficial	40% (21)	44% (122)
It is very beneficial	41% (22)	39% (109)

Question 5: Do you believe that complementary health practice is effective in treating disease?
	Student % (n)	Faculty % (n)
No, it is not effective at all, it is fake science	4% (2)	3% (7)
It is not very effective	2% (1)	4% (12)
I am undecided	26% (14)	23% (64)
It is somewhat effective	47% (25)	47% (132)
It is very effective	21% (11)	23% (66)

Question 7: Would you attend a forum to learn more about Complementary and Integrative Health?
	Student % (n)	Faculty % (n)
Never	2% (1)	1% (3)
Not likely	0% (0)	12% (33)
Maybe	27% (14)	27% (77)
Likely	45% (24)	36% (102)
Definitely	26% (14)	24% (66)

Question 9: Do you think the University should have a curriculum focused on Complementary and IntegrativeHealth?
	Student % (n)	Faculty % (n )
No, not at all	4% (2)	6% (16)
Probably not	4% (2)	7% (21)
Maybe	27% (14)	26% (74)
Probably	38% (20)	28% (78)
Definitely	27% (14)	33% (92)

Questions 3, 6, 8, and 10 were open ended responses with no numerical data to include in Table 1.

Discussion

CIH education provides opportunities to improve students' health and the health of their future patients. Complementary practices are being investigated as solutions to many health problems facing patients in the United States, including chronic pain, smoking cessation, obesity, and mental health.³ Chronic pain is a problem among many of these patients, including those with cancer, military personnel, and veterans. It is also one of the factors in the opioid epidemic currently wreaking havoc in the United States.¹⁰ The number of deaths from prescriptions and illicit opioid overdoses doubled from 21,089 in 2010 to 42,249 in 2016.¹⁰ CIH practices, such as acupuncture, are effective for the management of pain-related conditions¹¹ and are among the first-line treatment options for chronic low-back pain.¹²

Studies from the NCCIH have suggested that patients with cancer have less pain and anxiety when receiving integrative therapies in the hospital.³ Other prevalent causes of morbidity and mortality that can be reduced with CIH practices include smoking and obesity. Smoking is the leading cause for preventable disease and death in the United States, accounting for more than 480,000 deaths per year.¹³ Research has suggested that complementary techniques, such as yoga and meditation-based therapies, might help smokers to quit.³ More than one-third of the U.S. population is obese, a condition that accounts for some of the most prevalent preventable problems, including heart disease, type 2 diabetes, stroke, and some cancers.¹⁴ New research suggests that mind–body approaches, particularly mindful eating, can be beneficial for healthy weight-loss plans.³

Mainstream topics, including nutrition and exercise, should also be considered for emphasis in a CIH curriculum, as they are related to obesity as well as total body health and wellness. To be able to care adequately for patients with obesity, diabetes, metabolic syndrome, or hospital-related malnutrition, physicians require nutrition education; yet, a study by Adams et al. found that 71% of U.S. medical schools failed to provide this education.¹⁵ Exercise is known to have a number of wide-ranging benefits including reductions in risks for cardiovascular disease, type 2 diabetes, metabolic syndrome, cancer, and depression¹⁶; however, physician counseling on exercise is low across the United States,¹⁷ and the components of an exercise prescription are also not taught widely in medical schools.¹⁸

Large health-care organizations are now supporting options for complementary and alternative care. Kaiser Permanente promotes health and wellness through diet and exercise guides, support groups, information on drugs and natural medicines, and programs and classes that cover CIH topics such as mindfulness and yoga.¹⁹ The Veterans Health Administration (VHA) has recently instituted the Whole Health for Life model for evaluating wellness, in which multiple components of a person's well-being are considered with mindful awareness at the core.²⁰ This is significant for students of USUHS, as they do clinical rotations in the VHA and will care for patients who receive care both in the Department of Defense and the VHA. It is necessary to prepare students by exposing them to CIH topics, so these students are prepared for the future.

A further benefit of CIH is the mind–body help that some practices provide.³ Rates of depression and psychologic distress are higher among medical students than in the general population, which can have negative effects, through burnout, on performance academically and professionally.⁵ Medical students who are exposed to CIH methods will be able to discuss and recommend appropriate practices for their future patients and will also benefit personally by using CIH methods to manage their own health. In one study, perceived stress decreased and sense of well-being increased for medical students who engaged in 10–20 minutes of mobile-phone–guided mindfulness meditation.⁵ Another study of CIH curriculum integration found that students' health practices—including sleep, exercise, and stress management—improved together with their knowledge of, and comfort, with education on CIH practices.² Implementing mindfulness training into general medical school curricula could lead to less burnout, anxiety, and depression as well as improved physician and patient outcomes.⁵

Limitations

The response rate was relatively low, 6.7% for students (54/801) and 5.4% for faculty members (290/5339); thus, while there was a large total number of responses (344), it was not possible to be sure that they were completely representative of the entire faculty and student bodies. Due to the unique nature of the curriculum at USUHS, third- and fourth-year medical students are completing clerkships throughout the United States and, in some circumstances, other countries. Therefore, there is a smaller group of on-campus faculty members (∼ 500) who instruct the medical students on campus during the preclerkship period as well as the GSN students (∼ 460 total medical and GSN students). This geographic separation could have influenced the response rate negatively. There was low participation among the National faculty members, as 72.1% of the faculty responses came from the faculty located on campus. There is also historically a low response rate to surveys among students who are completing their clinical rotations.

In addition, due to the lack of demographic questions in the current survey, there was no demographic information about the respondents; thus, it is possible that more-polarized groups with a higher response rate could have skewed the data strongly for or against CIH. The reason for not asking for age or gender was to de-identify the respondents; however, there were limitations in that the responses might have been weighted toward one gender or age group.

Another limitation to consider is the phrasing of the questions and Likert-scale responses. Question 1 included a specific flaw, asking about current knowledge and experience, although it is possible to have one without the other. Some survey respondents expressed that they would have liked more latitude to agree or disagree with a portion of the question or to explain their answers.

Despite these limitations, the current authors believe the number of total responses received was enough to draw the conclusion that there was a favorable attitude toward instituting a formal CIH curriculum.

Conclusions

There is agreement among the students and faculty of USUHS who responded to the survey that a curriculum in CIH would be beneficial. There is also evidence from other institutions that students believe CIH curricula are very important for their future careers.⁸ Some of the current challenges to CIH integration include evidence-based teaching, crowding in a busy medical-school curriculum, and student involvement.²

A longitudinal study on evaluating the feasibility and effectiveness of the integration of an integrative health curriculum found that it was feasible to incorporate it into undergraduate medical education.² Given that the integration of a CIH curriculum has been shown to be possible, the next important points to establish are whether the CIH program will be mandatory or optional, when the best time to provide instruction would be, and what competencies the curriculum should strive to meet. A study of mandatory immersion curriculum in integrative health found that timing the curriculum near students' graduation during the fourth year, encouraging students' personal exploration of CIH modalities, and providing opportunities for students' interaction with CIH providers all helped to make the curriculum successful.²¹ The benefit to providing later training would be more opportunities for self-exploration of the field and continuing practices during residency. One downside to later training is that students would not be able to utilize the mindfulness practices they learn throughout medical school.

Another study of a mandatory curriculum for medical students across all years of medical school delivered content via lectures, small-group work, and wellness activities driven by the students.² At the end of the course, the students' knowledge of several integrative health practices increased, as did the students' personal health practices, such as those involving sleep, exercise, and stress management.²

Competencies within the realms of patient care and medical knowledge have been developed to ensure the quality of skills and knowledge provided by various organizations in the field of integrative health.²² These competencies were developed for integrative health fellowship training; therefore, adaptations could be made to make sure that they would be cohesive with what is taught at the medical-school level. Competencies in integrative health predominantly align with those shared by all medical specialties and subspecialties, except in the areas of medical knowledge and patient care.²² These competencies include advising patients on the risks and benefits of integrative health and demonstrating knowledge on evidence for CIH practices, as well as knowledge of how lifestyle factors can influence health.²²

In addition, the Consortium of Academic Health Centers for Integrative Medicine (CAHCIM) working group determined a list of proposed competencies to guide medical-education curriculum guidelines.²³ The competency development involved a 2-year collaboration of educators from many CACHIM institutions. The working group described, through these competencies, the values, knowledge, skills, and attitudes it believed to be essential to integrative health.²³ These competencies could be used for the development of a CIH education curriculum at the USUHS.

Recommendations

Based on the favorable responses of the students and faculty members, the current authors recommend moving forward to develop a CIH curriculum for the USUHS. To illustrate complementary modalities and current evidence on the practices, 1–2 hours of content related to each module topic should be incorporated into the organ systems–based module learning. During the transition to postclerkship, practical skills should be taught (e.g., breathing, meditation, mindfulness) that students can utilize for themselves and their patients during subsequent rotations. A variety of elective opportunities should be available, interwoven throughout the undergraduate medical education. Emphasis should be placed on mind–body topics (including meditation, mindfulness, etc.) and non-CIH topics related to leading a healthy lifestyle—including sleep, exercise, and nutrition—that should be a part of a standard medical-school curriculum. In addition, there should be a faculty position within the USUHS School of Medicine to coordinate the CIH curriculum and ensure that the competencies decided upon are being reached.

Appendix 1. Complimentary and Integrative Health Interest Survey

• 1.What is your current knowledge or experience concerning Complementary and Integrative Health practices (i.e., meditation, manipulation, acupuncture, etc.)?
• a.I have never heard of [them]
• b.I have only heard of [them]
• c.I have tried [them]
• d.I use [them] occasionally
• e.I use [them] routinely
• 2.Would you be interested in learning more about Complementary and Integrative Health?
• a.No, I'm not interested at all
• b.I am uninterested
• c.I'm neither interested nor uninterested
• d.I am interested
• e.I am very interested
• 3.If you are not interested, what would change your mind? (further, research, personal experience, etc.)
• 4.Do you think that Complementary and Integrative Health Practices have a role in modern medical treatment?
• a.No, [they are] not beneficial at all
• b.[They are] not very beneficial
• c.I am undecided
• d.[They are] somewhat beneficial
• e.[They are] very beneficial
• 5.Do you believe that complementary health practices are effective in treating disease?
• a.No, [they are] not effective at all, [they are] fake science
• b.[They are] not very effective
• c.I am undecided
• d.[They are] somewhat effective
• e.[They are] very effective
• 6.If you don't believe the practices are effective, what would change your mind?
• 7.Would you attend a forum to learn more about Complementary and Integrative Health?
• a.Never
• b.Not likely
• c.Maybe
• d.Likely
• e.Definitely
• 8.If you are undecided or unwilling to go, is there anything that would change your mind? And if so, what?
• 9.Do you think the University should have a curriculum focused on Complementary and Integrative Health?
• a.No, not at all
• b.Probably not
• c.Maybe
• d.Probably
• e.Definitely
• 10.What complementary health practices interest you most? (acupuncture, manipulation, meditation, etc.)

Author Disclosure Statement

No financial conflicts of interest exist.

CME Quiz Questions

Article learning objectives:

After studying this article, participants should be able to assess the results of a survey of medical student and faculty interest in learning about Complementary and Integrative Health and summarize the evidence from this survey for the inclusion of a structured curriculum of complementary and integrative health in medical schools.

Publication date: November 30, 2018

Expiration date: December 31, 2019

Disclosure Information:

Authors have nothing to disclose.

Richard C. Niemtzow, MD, PhD, MPH, Editor-in-Chief, has nothing to disclose.

Questions:

• 1.
  Identify the incorrect statement:

  • a.
    Complementary and Integrative Health (CIH) brings together standard western medical training with an array of practices and products that are outside the scope of usual western medical training.
  • b.
    In the United States, 40% of medical schools have membership in the Academic Consortium for Integrative Medicine and Health.
  • c.
    In the USA, approximately 50% of medical schools offer at least one CIH course or clerkship.
  • d.
    In a survey by the Royal College of Physicians, medical students in the UK felt that experience with integrative health was a vital component to their future careers.
  • e.
    In the Royal College of Physicians survey published in 2013, medical students felt that they were being adequately educated on the subject of integrative health.
• 2.
  Identify the incorrect statement:

  • a.
    At Uniformed Services University School of Medicine (USU) there are components of integrative and complementary health within the mandatory and elective coursework of the medical education.
  • b.
    The purpose of the authors' survey was to attempt to gauge the interest and readiness of the School of Medicine (SOM) and Graduate School of Nursing (GSN), faculty and students for a formal curriculum in Complementary and Integrative Health (CIH).
  • c.
    The data was collected by personal interview consisting of 10 questions and extensive follow up discussion.
  • d.
    Survey participants were faculty and students.
  • e.
    Responses from students away on clerkships were low.
• 3.
  Identify the incorrect statement:

  • a.
    70% of faculty and students believed that CIH was effective in treating diseases.
  • b.
    A higher percentage of faculty reported using CIH routinely than students (18%, 6% respectively).
  • c.
    90% of students reported being interested or very interested in learning more about complementary and integrative health.
  • d.
    77% of faculty reported being interested or very interested in learning more about complementary and integrative health.
  • e.
    The survey found that the majority of faculty and students were neither interested nor uninterested in learning more about CIH.
• 4.
  Identify the incorrect statement:

  • a.
    The majority of respondents felt that while CIH was important, there was no room in their training schedule for a CIH curriculum.
  • b.
    71% of medical and nursing students reported that they would likely or definitely attend a forum on CIH topics.
  • c.
    60% of faculty reported that they would likely or definitely attend a forum on CIH topics.
  • d.
    The authors cite a 2007 survey of Georgetown University School of Medicine preclinical medical students. In that survey, 91% of students agreed that Western Medicine could benefit from CIH ideas and methods.
  • e.
    85% of the Georgetown Medical School survey participants felt that knowledge about CIH is important as a future physician.
• 5.
  Identify the incorrect statement:

  • a.
    Among the student and faculty respondents there was a very broad range of interest in complementary methods.
  • b.
    Common CIH topics in which faculty and students expressed interest included acupuncture, manipulation, meditation, massage, nutrition, supplements, and yoga.
  • c.
    Approximately 42% of faculty respondents identified acupuncture as a CIH subject of particular interest.
  • d.
    Among student respondents, approximately 53% identified acupuncture as a CIH topic of particular interest.
  • e.
    Interest in the CIH topic of meditation was the least mentioned as an area of interest by students and faculty.

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