commentary: emerging educational needs of an emerging discipline

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THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE Volume 5, Number 3, 1999, pp. 269-271 Mary Ann Liebert, Inc. COMMENTARY Emerging Educational Needs of an Emerging Discipline JEFFREY M. DEVRIES, M.D., M.P.H. T he rapid growth of complementary and al- taught in residency training, do not mention ternative medicine (CAM) is illustrated by CAM philosophies or therapies. Similarly, the substantial increases in patient demand, media landmark Educational Guidelines for Residency coverage, number of practitioners, and—per- Training in General Pediatrics, published by the haps the ultimate substantiation of these other Ambulatory Pediatric Association in 1996 as a factors in the United States—the willingness of comprehensive compendium of educational medical insurance companies to pay for this goals and objectives, refers to CAM education therapy. The rapid growth in patient interest as an objective only once, as follows: "Identify and availability of CAM information through common home remedies or alternative treat- the lay press and Internet increasingly results ments which may be detrimental to the pedi- in physicians' embarrassing inability to answer atric patient, and identify physical signs or their patients' CAM-related queries. Many symptoms of common folk therapies or home physicians who are currently in practice ex- remedies (eg, cupping, coining)" (Ambulatory plain their lack of knowledge or interest in Pediatric Association, 1996). Thus, those who CAM not only through a lack of coverage of feel that CAM should be introduced into resi- this field of study in their medical training, but dency education—whether from a supportive as an active disdain for emerging CAM or critical viewpoint—are forced to promote its philosophies and therapies promoted without inclusion in an already crowded curriculum, adequate study or deliberation. Today, CAM and to identify educational goals, objectives, therapies are becoming increasing popular, and curricula, without guidance from national and the scientific basis and justification of educational societies. many of them is being increasingly demon- It is in this context that Kemper, Vincent, and strated. However, current trainees may not be Scardapane, whose evaluation of a CAM cur- receiving any more training in CAM than their riculum for family practice residents appears in predecessors. The most recent editions of the this issue (Kemper et al., 1999), are to be con- "Program Requirements for Residency Educa- gratulated—not only for developing a formal tion" in pediatrics (Accreditation Council for curriculum, but for their efforts to formally Graduate Medical Education, 1998a) (in effect evaluate its efficacy. Their curriculum con- since 1997), internal medicine (Accreditation sisted of an annual lecture to all residents about Council for Graduate Medical Education, integrating various types of therapy, and 10-12 1998b) (1998), and family practice (Accredita- individual sessions for senior residents on spe- tion Council for Graduate Medical Education, cific pediatric topics, integrating "mainstream" 1998c) (1997), written by the Accreditation and CAM therapies based on scientific evi- Council for Graduate Medical Education to set dence of effectiveness, safety, and cost. Resi- minimum standards for content areas to be dents were expected to prepare for individual Children's Health Services, Oakwood Healthcare System, Dearborn, Michigan. 269

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Page 1: Commentary: Emerging Educational Needs of an Emerging Discipline

THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE Volume 5, Number 3, 1999, pp. 269-271 Mary Ann Liebert, Inc.

COMMENTARY

Emerging Educational Needs of an Emerging Discipline

JEFFREY M. DEVRIES, M.D., M.P.H.

The rapid growth of complementary and al- taught in residency training, do not mention

ternative medicine (CAM) is illustrated by CAM philosophies or therapies. Similarly, the substantial increases in patient demand, media landmark Educational Guidelines for Residency coverage, number of practitioners, and—per- Training in General Pediatrics, published by the haps the ultimate substantiation of these other Ambulatory Pediatric Association in 1996 as a factors in the United States—the willingness of comprehensive compendium of educational medical insurance companies to pay for this goals and objectives, refers to CAM education therapy. The rapid growth in patient interest as an objective only once, as follows: "Identify and availability of CAM information through common home remedies or alternative treat-the lay press and Internet increasingly results ments which may be detrimental to the pedi-in physicians' embarrassing inability to answer atric patient, and identify physical signs or their patients' CAM-related queries. Many symptoms of common folk therapies or home physicians who are currently in practice ex- remedies (eg, cupping, coining)" (Ambulatory plain their lack of knowledge or interest in Pediatric Association, 1996). Thus, those who CAM not only through a lack of coverage of feel that CAM should be introduced into resi-this field of study in their medical training, but dency education—whether from a supportive as an active disdain for emerging CAM or critical viewpoint—are forced to promote its philosophies and therapies promoted without inclusion in an already crowded curriculum, adequate study or deliberation. Today, CAM and to identify educational goals, objectives, therapies are becoming increasing popular, and curricula, without guidance from national and the scientific basis and justification of educational societies. many of them is being increasingly demon- It is in this context that Kemper, Vincent, and strated. However, current trainees may not be Scardapane, whose evaluation of a CAM cur-receiving any more training in CAM than their riculum for family practice residents appears in predecessors. The most recent editions of the this issue (Kemper et al., 1999), are to be con-"Program Requirements for Residency Educa- gratulated—not only for developing a formal tion" in pediatrics (Accreditation Council for curriculum, but for their efforts to formally Graduate Medical Education, 1998a) (in effect evaluate its efficacy. Their curriculum con-since 1997), internal medicine (Accreditation sisted of an annual lecture to all residents about Council for Graduate Medical Education, integrating various types of therapy, and 10-12 1998b) (1998), and family practice (Accredita- individual sessions for senior residents on spe-tion Council for Graduate Medical Education, cific pediatric topics, integrating "mainstream" 1998c) (1997), written by the Accreditation and CAM therapies based on scientific evi-Council for Graduate Medical Education to set dence of effectiveness, safety, and cost. Resi-minimum standards for content areas to be dents were expected to prepare for individual

Children's Health Services, Oakwood Healthcare System, Dearborn, Michigan.

269

Page 2: Commentary: Emerging Educational Needs of an Emerging Discipline

270 DEVRIES

sessions by reading from a text written by one knowledge about the clinical effectiveness of of the authors and answering questions. At specific therapies for common childhood con-each session, the attending pediatrician re- ditions was assessed through ten true/false viewed the assigned questions, cited relevant questions. Residents in both groups scored articles, discussed recent clinical cases seen by well, with the few significant differences be-the resident, and conducted role-playing about tween the groups clearly attributable to infor-that session's topic. For purposes of evaluation, mation that was included in the CAM curricu-residents were compared with those from 3 Ium. Finally, in regard to behavior, there were family practice programs in the same geo- few significant differences in the rates of refer-graphic area, who may have had varying ex- ral for CAM therapy from residents in the 2 posure to CAM in practice and as part of their groups. Unfortunately, there is no assessment curricula, but who had not been exposed to this of whether the recommendations for CAM specific educational program. therapy were appropriate, or were consistent

Program evaluation was conducted by with the evidence-based teaching provided by mailed questionnaire. Although the overall re- the curriculum. sponse rate was a respectable 59%, compar- The underlying educational principles in-isons between residents from the intervention volved in the development and evaluation of and control programs were made difficult be- curricula in complementary and alternative cause of several factors. First, we do not know medicine are identical to those related to the whether residents from the 2 groups were com- curricula of any other area of clinical medicine, parable in their preresidency medical training Adult learning theory states that the learner or attitudes about the value of CAM. Second, must first be motivated to learn the presented the number of respondents in the intervention material. Although the disdain of clinical role {n = 18) and control {n = 21) programs were models and skepticism about the lack of a sci-not sufficient to achieve adequate statistical entific basis for CAM may have detracted from power. Third and, perhaps, most important, that motivation in the past, the authors present there was considerable intragroup heterogene- a convincing case for the motivation of current ity in the degree of exposure to a CAM cur- trainees to learn more about CAM, as a result riculum in residents from both the intervention of an increasing scrutiny of its scientific basis, and control programs. The exposure of the con- its growing popularity, and the desire to be trol residents to CAM curricula and clinical able to accurately answer patients' questions cases is unknown. Moreover, residents in the about its efficacy and safety. An appropriate intervention program reported that they had needs assessment must not only determine received widely varying proportions of the cur- whether CAM principles and therapies should riculum, ranging from 0-120 hours, with a me- be taught, but will identify the specific, desired dian of only 2 hours of what was planned as knowledge and skills that the residents should an 11- to 13-session program. This may be com- possess at the conclusion of the training period, pared to a clinical trial, in which members of This list of desired outcomes is then used to the "intervention group" are identified based identify clear educational objectives. These ob-upon "intent to treat," rather than on actually jectives can be classified as focusing primarily having received all of the planned intervention, on knowledge, attitudes, or behaviors, and In this study, the paucity of significant differ- each must be stated in measurable terms. The ences in outcome between the 2 groups may ac- subsequent development of a curriculum rep-curately reflect the difficulties of implementing resents the planned series of learning experi-this specific curriculum, but does not address ences of varying types that are designed to pro-the potential effectiveness of the curriculum if vide the opportunity to accomplish each of the it had been delivered as intended. predetermined objectives. Finally, a variety of

Residents from both groups expressed com- evaluation methods may be incorporated to en-parably favorable attitudes toward asking pa- sure that each educational objective has been tients about their use of CAM therapies and achieved. The results of this evaluation, to-working with CAM providers. Residents' gether with periodic updating of the needs as-

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EMERGING EDUCATIONAL NEEDS 271

sessment, are utilized on an ongoing basis to modify and improve the curriculum.

Kemper, Vincent, and Scardapane have called attention to the importance of identify­ing the need for an organized curriculum, ac­tually designing a curriculum, and evaluating its efficacy. They have laid the groundwork, and set the challenge, for future educators to build upon their efforts in designing curricula that meet the current and emerging needs of our students and residents.

REFERENCES

Accreditation Council for Graduate Medical Education. Program Requirements for Residency Education in Pedi­atrics. In Graduate Medical Education Directory: 1998-1999. American Medical Association; 1998a; 211-220.

Accreditation Council for Graduate Medical Education. Program Requirements for Residency Education in Internal

Medicine. In Graduate Medical Education Directory: 1998-1999. American Medical Association; 1998b; 79-88.

Accreditation Council for Graduate Medical Education. Program Requirements for Residency Education in Family Practice. In Graduate Medical Education Directory: 1998-1999. American Medical Association; 1998c; 66-74.

Ambulatory Pediatric Association. Educational Guidelines for Residency Training in General Pediatrics. Ambulatory Pediatric Association; 1996.

Kemper KJ, Vincent EC, Scardapane JN. Teaching an in­tegrated approach to complementary, alternative and mainstream therapies for children: a curriculum evalu­ation. / Alt Comp Med, 1999;5:261-268.

Address reprint requests to: Jeffrey M. Devries, M.D., M.P.H.

Oakwood Healthcare System 18101 Oakwood Boulevard

Dearborn, Ml 48123

E-mail: [email protected]