Wetzel MS, Eisenberg DM, Kaptchuk TJ. Courses Involving Complementary and Alternative Medicine at US Medical
Schools. JAMA. 1998;280(9):784-787. doi:10.1001/jama.280.9.784
Context.— With the public's increasing use of complementary and alternative medicine,
medical schools must consider the challenge of educating physicians about
Objectives.— To document the prevalence, scope, and diversity of medical school education
in complementary and alternative therapy topics and to obtain information
about the organizational and academic features of these courses.
Design.— Mail survey and follow-up letter and telephone survey conducted in 1997-1998.
Participants.— Academic or curriculum deans and faculty at each of the 125 US medical
Main Outcome Measures.— Courses taught at US medical schools and administrative and educational
characteristics of these courses.
Results.— Replies were received from 117 (94%) of the 125 US medical schools.
Of schools that replied, 75 (64%) reported offering elective courses in complementary
or alternative medicine or including these topics in required courses. Of
the 123 courses reported, 84 (68%) were stand-alone electives, 38 (31%) were
part of required courses, and one (1%) was part of an elective. Thirty-eight
courses (31%) were offered by departments of family practice and 14 (11%)
by departments of medicine or internal medicine. Educational formats included
lectures, practitioner lecture and/or demonstration, and patient presentations.
Common topics included chiropractic, acupuncture, homeopathy, herbal therapies,
and mind-body techniques.
Conclusions.— There is tremendous heterogeneity and diversity in content, format,
and requirements among courses in complementary and alternative medicine at
US medical schools.
AMONG THE MANY forces influencing the present health care environment
is the rapid increase in the use of complementary and alternative medical
therapies. We have known for several years that approximately 1 in 3 adults
in the United States uses chiropractic, acupuncture, homeopathy, or one of
many other treatment modalities.1 Reasons cited
for the trend toward the use of alternative therapies include dissatisfaction
with conventional health care that is perceived as ineffectual, too expensive,
or too focused on curing disease rather than maintaining good health.2 Alternative therapies are often seen as less authoritarian
and more congruent with patients' values and beliefs about the meaning of
health and illness.3 Medical educators increasingly
realize that it is not a question of whether to address these issues in the
education of future physicians but rather how to respond to this relentless
challenge to evolve.4
In 1997, the Group on Educational Affairs of the Association of American
Medical Colleges (AAMC) announced the formation of the Special Interest Group
in Alternative and Complementary Medicine.5
The Society of Teachers of Family Medicine6
and the American Public Health Association7
have also recently formed special interest groups around complementary and
alternative therapies,7 and the Federation
of State Medical Boards has urged the development of educational opportunities
for licensees, consumers, and legislators in this area.8
The American Medical Association (AMA) has recognized the need for medical
schools to respond to the growing interest in alternative health care practices.
A 1997 report on "Encouraging Medical Student Education in Complementary Health
Care Practices" responded to a request for the AMA to "study the development
of a model elective curriculum for increasing awareness of the prevalence
and potential impact of various complementary/alternative health care practices
on patients' health" by concluding that "medical schools should be free to
design their own required or elective experience related to alternative/complementary
health care practices."7
Results of the 1996-1997 and 1997-1998 Annual Medical School Questionnaire
Part II distributed by the Liaison Committee on Medical Education indicate
a notable increase in instruction in "alternative medicine." Although no medical
school reported offering a separate required course in complementary health
care practices, medical schools covering these areas as part of a required
course increased to 63 (from 46 in 1996-1997) and medical schools offering
a separate elective course increased to 54 (from 47 in 1996-1997). In the
1996-1997 academic year, 34 medical schools offered instruction as part of
an elective course, and 28 offered other educational experiences.
The purposes of our study were to document the prevalence, scope, and
diversity of medical school education in complementary and alternative medicine
topics and to compile information about the organizational and academic features
of these courses.
In January 1997, we sent a mail survey to all 125 US medical schools
listed in the Directory of American Medical Education.9 A 1-page letter stated that the survey intended to
document the scope and diversity of medical school education in complementary
and alternative medicine, defined as treatment modalities not traditionally
taught in Western medical schools, such as chiropractic, acupuncture, massage,
and homeopathy,1 although we are aware that
other terms such as integrative medicine and unorthodox medicine are frequently used and often preferred.
The questionnaire was sent on a standard-sized postal card along with a letter.
The survey was addressed to the highest-ranking individual listed at each
medical school who appeared to have curriculum responsibilities, typically
with the title of associate dean for academic affairs, associate dean for
medical education, or assistant dean for curriculum.
We sent a follow-up letter in September 1997 to schools that did not
respond to the postal card survey and to those that reported no courses in
complementary and alternative medicine, and we inquired whether plans had
changed for the coming academic year. Schools included on previously published
lists as having complementary and alternative therapy courses were contacted
by telephone, and schools reporting affirmatively were asked for additional
information about their courses. We systematically recorded data in the following
10 categories: name of course(s); sponsoring department(s); type of course
(required, elective, part of a required course, part of an elective course);
academic credit (yes or no); number of students enrolled per year in each
course; type of students (medical, nursing, or other); format of course (seminar,
faculty lecture, practitioner lecture or demonstration, patient presentation,
or other); teaching methods (lecture, case study, demonstration, observation,
or other); amount of scheduled time; and academic requirements (readings,
examination, paper, or project). We also invited schools to send course descriptions
or syllabi. We completed follow up with the schools in April of 1998.
We received replies from 117 (94%) of the 125 US medical schools contacted.
Of the 117 schools responding, 75 (64%) reported offering 1 or more courses
in complementary and alternative medicine or including these topics in required
courses (Table 1). The majority,
47 (63%) of 75 schools, offered a single course and 28 (37%) offered 2 or
more courses. A total of 123 courses was reported. Twenty-nine schools provided
additional details or sent syllabi, course descriptions, course objectives,
or other information. The data were organized into 2 categories. The descriptions
of organizational aspects of the courses are shown in Table 1 and the educational features are shown in Table 2.
All of the free-standing complementary and alternative medicine courses
for medical students are currently offered as electives. Thirty-one schools
(41% of those reporting courses) reported 38 courses that include complementary
and alternative medicine topics (eg, prevalence, relevance for interviewing
skills) as a component of a required course. These topics are frequently found
in introduction to clinical medicine or patient-physician communication courses
in the first or second year, with electives typically offered in the third
and fourth years. Seventeen schools reported both 1 or more elective courses
and complementary and alternative medicine topics as part of a required course.
The amount of time scheduled for elective courses ranged from 6 to 160
contact hours, with only 9 schools reporting courses of more than 100 hours.
Of these, 5 schools were characterized as having clerkships or rotations:
University of Florida College of Medicine, Gainesville; Georgetown University
School of Medicine, Washington, DC; Jefferson Medical College of Thomas Jefferson
University, Philadelphia, Pa; Marshall University School of Medicine, Huntington,
WVa; and the University of New Mexico School of Medicine, Albuquerque. The
remaining 4 with longer courses—the University of Cincinnati College
of Medicine, Cincinnati, Ohio; Cornell University Medical College, New York,
NY; Johns Hopkins University School of Medicine, Baltimore, Md; and the University
of Maryland School of Medicine, Baltimore—were listed as having 3- or
4-week electives with up to 6 or 7 hours of class per day. Other typical configurations
of complementary and alternative medicine courses were 1 or 2 hours per week
for 10, 12, or 15 weeks. Hours devoted to complementary and alternative medicine
topics in required courses ranged from 2 to 10, with an average of 4.5 hours.
Predominant departmental affiliations of complementary and alternative
medicine courses are shown in Table 1.
Nine courses were offered by separate institutes or centers affiliated with
universities or medical schools, such as the Institute for the Study of Health
and Illness, which sponsors a course offered by the University of California,
San Francisco, School of Medicine; the Center for Spirituality and Healing
at the University of Minnesota, Minneapolis; and the Center for Mind-Body
Medicine, affiliated with Georgetown University. Five schools listed the sponsoring
department as interdisciplinary, integrated, or interdepartmental. Other courses
are affiliated with a wide variety of departments, ranging from pathology
to the office of the university chaplain.
Sixty-two (91%) of the 68 schools that provided information on academic
credit awarded credit to students taking 97 complementary and alternative
medicine courses. Eight were noncredit courses and 7 schools (9%) did not
provide this information for an additional 18 courses.
The average number of students per elective course was 16, ranging from
5 students or fewer in clinical electives to 40 or more students in several
well-established courses. The majority of courses listed were offered to medical
students only. In a few interdisciplinary courses, such as nursing, pharmacology,
or public health, other graduate or undergraduate students were eligible for
enrollment and university credit. Course format and teaching methods are shown
in Table 2.
The most frequently cited other educational features included visits
to centers offering complementary and alternative medical therapies (n=22)
and observational or preceptorial experiences with providers of these treatments
(n=5). Among the unique formats offered was a culture, communication, and
health day at Allegheny University School of Medicine, Philadelphia, Pa. This
feature was included in a required second-year course in community and preventive
medicine. Students in groups of approximately 20 met and interviewed 2 consumers
of a variety of cultural or religious health belief systems not usually encountered
in medical school courses. The student complementary and alternative medicine
interest groups at University of California, Davis, School of Medicine and
Stanford University School of Medicine, Stanford, Calif, organized a yearly
seminar series with lectures and discussions on a broad range of topics.
Several unique teaching methods were reported in addition to the predominant
lectures, discussions, and case studies. At the University of Mississippi
School of Medicine, Jackson, a 3-hour senior seminar was presented in a required
course for 100 medical and 95 pharmacy students, which incorporated lecture
and a multistation teaching exercise. Brown University School of Medicine,
Providence, Rhode Island was the only school reporting the use of standardized
patients for practice in interviewing about the use of complementary and alternative
Course requirements varied greatly among the 61 schools reporting these
details. Forty-five schools (74%) assigned required readings, and 34 (56%)
required a paper or project. Of the 53 schools that provided this information,
only 10 (19%) gave a final examination.
From the information provided, only a few courses could be determined
to emphasize critical reading of existing research or epidemiological studies.
Washington University, Medical School, St Louis, Mo, lists "literature appraisal
and discussion" among its major teaching goals, and the elective course in
complementary medicine at the University of Maryland is "structured around
a strongly evidence-based curriculum." The course at Harvard Medical School,
Boston, Mass, emphasizes critical reading of the literature and discussion
of data from controlled trials relating to the efficacy and mechanisms of
action for specific alternative therapies. As a final required project, each
student designs and presents a detailed plan for a controlled clinical trial
of a chosen alternative therapy.
A summary description of individual course titles, methods, and teaching
formats obtained from the 117 responding medical schools is available on request
from the authors.
Medical education is under constant pressure to evolve.4
Changes in the medical interview over the past few years mirror this evolution.
Where once value-laden issues about human sexual behavior, resuscitation preferences,
and domestic violence were considered taboo in the physician-patient dialogue,
these topics are now mandatory as a part of responsible medical care. The
rapid increase of public interest in and use of complementary and alternative
therapies is likewise exerting a powerful influence on medical education.
In a study exploring the attitudes of 180 family physicians, Berman
et al10 found that physicians had a high degree
of interest in complementary and alternative medicine. Blumberg et al11 found similar results in 572 responses to a survey
of primary care internists. More than half indicated that they would encourage
patients who raise the possibility of complementary and alternative medicine,
and 57% were willing to refer their patients for treatment for 6 or more complementary
and alternative therapies.
In a speech to faculty and students, the dean of Harvard Medical School,
Joseph B. Martin, said that he had "come to believe that it is through the
establishment of a unique doctor-friend-patient relationship that most of
the healing occurs, whether helped along by surgery, acupuncture, or regular
doses of approved medicines."12 A 1995 survey
by Carlston et al6 of the frequency and nature
of alternative medicine instruction in US medical schools and family practice
residency programs reported that 33 medical schools and 75 family practice
residencies offered instruction in complementary and alternative medicine
and additional schools and family practice residencies were planning to add
complementary and alternative medicine instruction.
Data collected in our survey demonstrate tremendous heterogeneity in
content, format, and requirements among complementary and alternative medicine
courses at US medical schools. This area of the medical curriculum is at an
early stage of development and appears to have few guiding principles. A daunting
aspect of this situation is the sheer number of topics subsumed under the
rubric of alternative medicine. In 1992, Murray and Rubel13
named 4 basic categories of complementary and alternative therapy and called
the field "a muddle of names, beliefs, and practices." A report to the National
Institutes of Health named 6 main complementary and alternative medicine categories
with up to 11 subheadings,14 and another report
noted that there are more than 150 different therapies with a wide range of
philosophies and practices.10 The difficulty
in defining inclusion criteria and terminology to adequately categorize complementary
and alternative therapies underscores the need for a coordinated effort to
develop acceptable curricula.
In our study, we did not specifically survey topical content, but the
curriculum materials provided by 29 medical schools indicate that most include
acupuncture, chiropractic, massage, therapeutic touch, homeopathy, nutrition,
herbal medicine, and mind-body techniques. Several courses focus on spirituality
and faith. Other courses have a public health, epidemiological, or biostatistical
perspective, with their principal focus on rules of evidence and critical
reading of relevant medical literature. Asian and Native American ethnomedicine
is well represented in several courses, while other courses are based on a
humanistic or human potential viewpoint. Several schools have courses designed
and taught by faculty with a folklore background. Many courses appear to have
the objective of introducing the student to the diverse forms of complementary
and alternative medicine.
Our survey also did not inquire about complementary and alternative
medicine courses at the 19 US osteopathic medical schools. According to information
from the American Association of Colleges of Osteopathic Medicine, such courses
have been discussed, but data on courses on complementary and alternative
medicine are not available (Lorrie Van Akkerson, oral communication, 1998).
The nature of the courses offered in a particular medical school frequently
is determined by the interests and familiarity of the course directors and
the availability of local practitioners willing to participate with lectures
or demonstrations. Although this approach has made many courses possible where
they would not otherwise exist, it tends to foster instability and lack of
planned coherence in the curriculum.
Students have had an enormous influence on the development of complementary
and alternative medicine courses. In addition to the University of Alabama
School of Medicine, Birmingham, and University of California, Davis, student
groups have been active at the University of Chicago Pritzker School of Medicine,
Chicago, Ill; the Indiana University School of Medicine, Indianapolis; Washington
University; Harvard University, Boston, Mass; and elsewhere. Frequently, student-initiated
"brown bag" lunches with complementary and alternative therapy practitioners
mark the beginning of interest in establishing a formal course.
A recent AAMC report on the Medical School Objectives Project refers
to the importance of physicians being "sufficiently knowledgeable about both
traditional and nontraditional modes of care to provide intelligent guidance
to their patients."15 Clearly, the daunting
task is to move toward the establishment of a more coherent approach to complementary
and alternative therapies in the medical curriculum. Institutional support
is necessary to create and maintain viable and sustainable academic offerings.
We did not track these issues, but future surveys should include questions
about the curriculum, such as the following: Do the students, faculty, or
both initiate the course(s) in complementary and alternative medicine? Do
they require curriculum committee approval? Is there a budget and how is it
allocated? Are courses scheduled into the formal curriculum or "add-on" electives
scheduled over lunch or in evening or weekend hours? Is the course director
a paid faculty member or volunteer? Does the school provide administrative/secretarial
assistance? What percentage of students per class take the course(s)?
As the discussion of incorporating complementary and alternative medicine
topics appropriately into the medical curriculum evolves and broadens among
medical faculties and professional organizations, we offer several suggestions
based on information gathered in our survey and our experience with 5 years
of offering an elective course in complementary and alternative medicine.
Focus on critical thinking and
critical reading of the literature. Accepted scientific rules of evidence
must be applied to complementary and alternative medicine and will serve as
a sound basis for decision-making concerning the recommendation of any intervention.16 Evidence-based strategies to distinguish useful from
useless interventions can be a central theme.
Identify thematic content (ie,
therapies and conditions to be formally addressed) and express the chosen
topics in clear, concise learning objectives. An introductory course
would likely include chiropractic, acupuncture, massage, herbal medicine,
homeopathy, mind-body therapies, and placebo-related phenomenology as representative
of the majority of complementary and alternative practices.1
Other topics can be added based on student or faculty interest. Physicians
and educators can contribute to this discussion through the AAMC Special Interest
Include an experiential component. Experiencing acupuncture or therapeutic massage or tasting a macrobiotic
meal adds a dimension to the learning experience that a lecture or simple
demonstration cannot. The deeper understanding that results should provide
a better basis for responsibly advising patients.
Promote a willingness to communicate
professionally with alternative health care clinicians. Invite clinicians
of alternative therapies to share strategies for responsible comanagement.
Have students anticipate and develop strategies to address contradictory opinions
Teach students to talk to patients
about alternative therapies. Introduction to clinical medicine or the
patient-physician relationship should include opportunities to interact with
real or standardized patients in role-play situations involving complementary
and alternative medicine. Guidelines emphasizing safety and shared decision
making exist for these exercises.18
In conclusion, patients are increasingly seeking to identify a physician
who is solidly grounded in conventional, orthodox medicine and is also knowledgeable
about the value and limitations of alternative treatments. The discussion
about how best to prepare future physicians for this role is only beginning.
As with most newly defined challenges, this role is temporarily ill defined
and multifaceted and requires refinement.
As a profession, physicians will increasingly be expected to responsibly
advise patients who use, seek, or demand complementary and alternative therapies.
We believe the development of a more consistent educational approach to this
provocative area is essential.