The Need Assessment of Medical Students for a Complementary and Alternative Medicine Curriculum

Introduction

Complementary and Alternative Medicine (CAM) includes a variety of treatments that are outside the paradigm of ordinary medical practice and are often used in conjunction with or in combination with this method. In general, CAM can be mentioned as a group of treatments which have a more comprehensive approach towards medical problems, in comparison to conventional monotherapy treatments that may only consider the "mechanism of the body". Many types of CAM have been created by non-western countries and it is based on the true culture in these communities (1). WHO report mentions that around 75% of the world population act towards indigenous medical techniques or traditional systems (2).

At the start of the 21st century, the report by Flexner identified controversy in the medical curriculum of medical schools of the United States. The findings of this stage report was set at standardizing conventional medical education emphasizing on biomedical sciences, technology, pharmacology and scientific methodology. Therapeutic approaches which were alternative and non-biomedical were removed from the medical curriculum. In the 1970s, the revitalization in public interest towards natural, global and foreign treatments in the U.S. and professional endeavors were pursued through a number of different fields including massage therapy, naturopathy and acupuncture. In the following studies on American adults, a great number of patients using alternative treatments along with inspiration were explicitly stated, cases who generally did not talk about their alternative treatment with their doctor (3).

Therefore, training of complementary and alternative medicine (CAM) once again was inserted into the college curriculum. CAM is not a single approach, so it is often described in terms of undeniable conditions or what is not present. These approaches are therapeutic and are not a major part of the biomedical system or are topics that are not commonly used in medical education. There are several suggestions for why knowledge about CAM is necessary for future physicians. It is believed that knowledge on CAM treatments can increase the positive attitude towards them. General knowledge on the theories and practices of well-known CAM treatments can help a doctor better consult his patient about his/her healthcare choices (4, 5).

It has been estimated that over 80% of the population in low-income countries use herbal remedies as part of their principal healthcare. The use of traditional, complementary and alternative medicine has also increased in countries with a high income. In response to the association between traditional, complementary and alternative medicine in primary healthcare throughout the world, WHO has repeatedly confirmed its support for the development of traditional, complementary and alternative medicine over the last decade. In the 2008 congress, WHO published the Beijing statement on traditional medicine. This statement was based on the framework of traditional, complementary and alternative medicine policies, responding to governments around the world and reaffirming the importance of integrating traditional, complementary and alternative medicine among members of the Health System Committee. One of its most important guidelines was to strengthen the relationship between biomedical doctors with traditional, complementary and alternative medicine as well as developing educational programs on traditional, complementary and alternative medicine for medical doctors and students (6-9).

Methods

This was a descriptive cross-sectional study. The study population in the first stage consisted of 15 medical professors and students (5 prof. of CAM, 5 prof. of clinical medicine and 5 medical students) who were selected based on purposive sampling. In this stage according to the Delphi method (in 3 rounds) the opinions were combined and a structured questionnaire was designed. In the 2nd stage the content validity of the structured questionnaire prepared in the first stage was determined by ten experts and professors in the fields of medical education, traditional and complementary medicine. The reliability coefficient for the questionnaire items in the 2nd stage was calculated as 89.6% with the SPSS software and based on Cronbach's alpha. The main target community in this study was the faculty members of the medical school.  By using Cochran's formula the sample size was calculated as 169 cases. In the 3rd stage, the designed questionnaire was filled in by the sample population.

Results

After collecting the data and performing statistical analyses the following results were obtained. Among the 169 studied cases 130 (77%) were male. 56 (33.13%) were in the 30-40 year age group, 85 (50.29%) in the 41-50 year age group, 23 (13.60%) in the 51-60 year age group and 5 (2.98%) in the over 60 years age group. The percentage of agreement and related and required topics in the field of complementary and alternative medicine are described in the tables below (tables 1-5)

Table 1. Percentage of Persons Agreeing on the Need for a Student's Curriculum on Complementary and Alternative Medicine

Table 2. Percentage of Persons agreement on the needs of the General Medical Student's Curriculum on Acupuncture

Table 3. Percentage of Persons agreement on the needs of the general medical student's curriculum on chiropractic

Table 4. Percentage of Persons agreement on the needs of the general medical student in the field of yoga, Tai chi, spiritual healing and relaxation

Table 5. Percentage of Persons agreement on the needs of the general medicine student in the field of herbal medicine

Other results are divided into the agreed topics as follows:

 Regarding homeopathy the percentage of total agreement in the diagnostic basic was 33.12%, treatment principles were 53.24% and common complications in its application was 53.24%. In terms of reflexology the total agreement percentage in the diagnostic basic was 53.245, its treatment principles was 56.79% and common complications 53.24%. In the field of hypnosis therapy the percentage of total agreement in the diagnostic basic was 53.83%, treatment principles 46.73% and common complications 80.46%. The same figures were 43.18%, 40.22% and 43.77% in wet and dry cupping and 73.36%, 73.95% and 70.4% for massage therapy.

Discussion

Based on the obtained results, the first need of the medical student's curriculum is to learn about the diagnostic basics, the principles of treatment and common complications in the field of yoga, tai chi, spiritual healing and relaxation. Accordingly, the second and third educational priorities are acupuncture and herbal medicine, respectively. Regarding the many researches performed in the field of traditional, complementary and alternative medicine, the results emphasize on this point. Quartey et al. in a systematic review have stated that based on the performed estimations over 80% of the population in low-income countries apply herbal medicine in the main healthcare sector whereas the use of traditional, complementary and alternative medicine has increased among high-income nations as well. Therefore, teaching courses on traditional, complementary and alternative medicine for Western physicians seems to improve the attitude, knowledge and skills of both medical doctors and medical students towards the use of traditional, complementary and alternative medicine. However, due to the methodological limitations of present studies, a comprehensive conclusion cannot be obtained (6, 10).

Davati et al. (11) in their research acknowledged that based on a study performed in 2000, physicians are paying particular attention to complementary and alternative therapies, yet there are some concerns due to the lack of scientific evidence on the efficacy of such therapies and lack of proper coding rules. Moreover, in a study conducted in Iran on 340 general physicians, 84% believed that in recent years the use of these methods has been considered more than ever before. Herbal medicine, cupping and acupuncture are the most commonly used traditional medicines in Iran (11). The findings of the latter study were consistent with that of the current study, namely, the acquisition of the second and third rank in the need metrics for acupuncture and herbal medicine. Regarding the findings of this study in which yoga, spiritual healing, acupuncture and chiropractic received the 1st to 4th rank in the need assessment; in the study by Solimani et al. regarding the attitude of medical students and residents on complementary and alternative medicine, this point has been well-documented that treatment with alternative and complementary medicine is becoming more and more popular every day. It is estimated that among each three individuals, one has used such treatments for common diseases such as low back pain, headache, anxiety and depression. Planning systems in developed countries aim to include certain CAM courses in their medical students' curriculum so that it can help the doctor and his/her patient to choose the best treatment option with the least complications (12).

Evad et al. performed a research on knowledge, attitude and motives towards complementary and alternative medicine treatments among medical and pharmacology students in Kuwait. He reported that the students need further and better education on complementary and alternative medicine to be able to better treat their patients in the future. Spiritual healing (Prayer and Quran reading), herbal products and massage therapy are considered as the most effective methods (13). In our study, spiritual healing achieved the 1st, herbal therapy the 3rd and massage therapy the 9th rank in this respect. Given that in each society there are certain medical beliefs that influence both the physician and the patient’s choice, complementary and alternative medicine training policies at medical universities should be designed on this basis (14). The curriculum of the medical students of the Medical Faculty of Mashhad University of Medical Sciences is based on the views of the faculty members which have been identified with respect to the conditions and beliefs in this region. Nevertheless, the findings of this research along with those of other studies emphasize on the necessity of implementing a standard educational program in the field of complementary and alternative medicine in the medical students' curriculum.

Mousavizadeh and Ansari in their study entitled " Complementary/alternative medicine and medical education", after discussing the complementary and alternative medicine and its place in the health services and the reasons for its acceptance and disapproval, its dynamics in the medical and medical education curriculum, as well as the status of complementary and alternative medicine training in today's world, concluded that although in many medical schools in the industrialized countries complementary and alternative medicine are taught, the educational programs for this medicine are variable and often superficial. In spite of the increasing attention, a standardized curriculum for teaching complementary and alternative medicine for medical doctors has not yet been developed (15).

Accordingly, it has been clearly stated that despite the worldwide tendency to use complementary and alternative medicine along with conventional treatments, the Medical Faculty of Mashhad University of Medical Sciences has not been effectively addressed yet. CAM has been recently included in the medical curriculum as two optional courses for medical students (a superficial look to the performance of complementary and alternative medicine in the medical students' curriculum). Therefore, it is necessary for educational planners and administrators to consider this topic more than before.

Lee et al. in another study entitled "complementary and alternative medicine and medical students in Australia: where do we stand?"stated that widespread support and the need for complementary and alternative medicine means that CAM is something that is likely to remain. Given the great popularity and potential of harm, we, as future physicians, have to be interested in this aspect of treatment and must actively participate in CAM discussions with patients, especially when many people believe that they are being judged intensely, their practitioners should disclose this. We ought to definitely maintain an open mind towards them (1).

In addition to the data on the substantive nature and acceptability of complementary and alternative medicine in medical and health societies worldwide, the other aspect which should be considered regarding this field of clinical science is its legal and ethical issues. Taghipour et al. in a systematic review focused on the ethical and legal challenges in complementary and alternative medicine. The mentioned topics in this study showed that complementary and alternative medicine for being applicable and defendable in legal assemblies require the development or revision of relevant and specific laws.

The process of dealing with errors and failures and their references should be specified and the type of punishment and penalties need to be defined; in addition, the authorities must provide the necessary documentation and training. On one hand, the national interest and coherence of the medical community in accepting this fact along with adopting educational and research approaches and correcting and updating traditional medicine texts and on the other hand, compilation and review of laws by legal and medical authorities are required, that can be presented in executive programs with determined schedules (16). Although in our study the legal and ethical aspects of complementary and alternative medicine was not discussed, but it was an issues of concern in the need assessments done, concerning the majority of faculty members on this type of treatment. This is due to the lack of valid evidence and strong evidence-based medicine capable of convincing such members.

In a study conducted by Cowen and Cyr in 2015, they stated that the study of CAM evidence-based methods can help doctors refer more patients to CAM treatments. Nevertheless, reference to licensed CAM providers is not required for the treatment and insurance pay back in the United States whereas other referrals for CAM treatment can have a potential responsibility. Experimental treatment with CAM and the use of CAM methods for self-care may be beneficial in the improvement of medical empowerment and cultural competence in medical students. However, there are certain questions regarding the efficiency of CAM and the potential risks for the patients' health, the introduction of ethical issues in CAM training for medical students especially when it includes participation or receiving treatment. The previous polls showed that 64% and 84% of medical schools provided CAM training. The scope of these reports, which were published in 1998 and 2002, respectively, along with the display of a few medical schools showed that further studies on CAM are required in the medical curriculum (4).

Given the many researches and studies performed on awareness and attitude towards CAM throughout the world, it can be concluded that the application of this medicine is increasing and developing day by day in a way that in developed and developing countries the trend toward using CAM therapeutic options are a priority in comparison to the conventional and modern treatments.

However, one should keep in mind that CAM is never intended to deny modern medicine, but complementary and alternative medicine can be beneficial to patients besides modern medicine. Therefore policymakers and educational planners need to pay attention to this trend and respond to this need of the community through proper planning. It means that by implementing appropriate courses for medical students, expert physicians can be trained for the future.

The issue of most concern for experts and faculty members in the clinical field, is the type of training and the relevant educational resources. In other words the evidence-based basis of this science is still a matter of question. However, with scientific scholars and expert professors in CAM, and the presence of scientific centers, educational institutions and reputable faculties throughout the world, one can be sure that acceptable planning can be done in this regard. Moreover, by conducting further and more precise studies in CAM, it is possible to promote the status of this medicine in scientific societies.

Acknowledgement

The authors would like to thank the professors of the Medical Faculty and the Traditional and Complementary Medicine Faculty of Mashhad University of Medical Sciences for their kind cooperation throughout this research. We do hope that the results, although small, help improve the planning and policies of administrators towards raising the level of knowledge of future physicians about complementary and alternative therapies.

Financial support: This article is extracted from MSc dissertation with code 960154 registered in Mashhad University of Medical Sciences.

Conflict of interest: The authors have no conflict of interest to declare.