Complementary and alternative medicine (CAM) has

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1 Status of Complementary and Alternative Medicine in the Osteopathic Medical School Curriculum Dale W. Saxon, PhD; Godfrey Tunnicliff, PhD; James J. Brokaw, PhD, MPH; Beat U. Raess, PhD Reflecting society s interest in complementary and alternative medicine (CAM), most allopathic medical schools in the United States offer instruction in CAM. Pertinent information about the teaching of CAM at osteopathic medical schools is lacking. The authors therefore sought to document the form and content of CAM instruction at osteopathic medical schools and compare their findings with those reported for allopathic medical schools in a recently published survey. Phone conversations with academic officials at each of the 19 colleges of osteopathic medicine revealed that only one school did not teach CAM. With the help of these officials, the authors identified 25 CAM instructors at 18 osteopathic medical schools and sent them questionnaires. All returned a completed form with details about CAM instruction at their schools. The authors found that CAM material was usually presented in required courses sponsored by clinical departments, was most likely taught in the first 2 years of medical school, and involved fewer than 20 contact hours of instruction. The topics most often taught were acupuncture (68%), herbs and botanicals (68%), spirituality (56%), dietary therapy (52%), and homeopathy (48%). Most (72%) CAM instructors were also practitioners of CAM modes of therapy. Few (12%) of the instructors taught CAM from an evidence-based perspective. The authors conclude that the form and content of CAM instruction at osteopathic medical schools is similar to that offered at allopathic medical schools and that both osteopathic and allopathic medical schools should strive to teach CAM with less advocacy and more reliance on evidence-based medicine. Dr. Saxon is an assistant professor in the Department of Anatomy and Cell Biology at Indiana University School of Medicine in Evansville, where Dr. Tunnicliff is a professor in the Department of Biochemistry and Molecular Biology and Dr. Raess is a professor in the Department of Pharmacology and Toxicology. Dr. Brokaw is an assistant dean in the Office of Medical Student Affairs and an associate professor in the Department of Anatomy and Cell Biology at the Indiana University School of Medicine in Indianapolis. Address correspondence to James J. Brokaw, PhD, MPH, Office of Medical Student Affairs, Indiana University School of Medicine, Medical Science Building, Room 164, 635 Barnhill Dr, Indianapolis, IN jbrokaw@iupui.edu Complementary and alternative medicine (CAM) has been broadly defined as a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine. 1 Consumers are using CAM modes of therapy in ever-greater numbers, and physicians should be trained to recognize the potential for harm some of these modalities pose when used alone or in combination with conventional treatments.2-4 Many patients will want to discuss CAM treatment options with their physicians, and physicians should be sufficiently versed to advise them intelligently. Published surveys indicate that allopathic medical schools in the United States have responded to this educational need by incorporating CAM into their curricula.5-7 As of 1998, at least 60% of the nation s 125 allopathic medical schools were teaching CAM topics in required or elective courses.6 It is anticipated that this percentage will grow as advocates of CAM press their case for further integration into the medical school curriculum.8 Osteopathic physicians make up an important segment of today s health care system, though little is known regarding the extent of CAM instruction in the undergraduate training of osteopathic physicians. The purpose of this study is to compare the form and content of CAM instruction at osteopathic medical schools with that offered at allopathic medical schools. A recent report documenting the teaching of CAM at allopathic medical schools will provide the basis for comparison.7 The historical arc of osteopathic medicine from a fledgling profession at odds with medical orthodoxy to its present status evinces a successful therapeutic paradigm. But osteopathic medicine was once regarded as alternative, with considerable opposition from mainstream medicine.9 Given this history, we posited that osteopathic medical schools might be more open-minded when dealing with unconventional modes of therapy and therefore more disposed to teach CAM compared to their allopathic counterparts. Methods At the time of this study, there were 19 osteopathic medical schools approved by the Bureau of Professional Education of the American Osteopathic Association (AOA). We collected the names and addresses of academic administrators from the official Web site maintained by the American Association of JAOA Vol 104 No 3 March

2 Table 1 Characteristics of Courses in Complementary and Alternative Medicine Taught at Osteopathic Medical Schools, 2002 Characteristic Respondents, % Type of course Required 64 Elective 28 Unspecified 8 Course taught with multiple instructors Yes 72 No 20 Unspecified 8 Year of curriculum in which course was taught* First 60 Second 52 Third 8 Fourth 4 Unspecified 12 Total hours taught in course Type of sponsoring unit Clinical sciences 60 Basic sciences 12 Other/unspecified 28 (continued) Table 1 (cont.) Characteristics of Courses in Complementary and Alternative Medicine (CAM) Taught at Osteopathic Medical Schools, 2002 Characteristic Respondents, % Instructional formats used Instructor lectures 92 Guest seminars 40 Group discussions 36 Case studies 36 Clerkships 8 Internet-based 16 Other 24 Principal course objective Broad survey of CAM therapies and concepts 60 Critical evaluation of the scientific literature regarding CAM 12 Practical training in the use of specific CAM treatments 20 Other/unspecified 16 Course taught by a CAM practitioner/ prescriber Yes 72 No 12 Unspecified 16 *Column total exceeds 100% because some respondents taught CAM in more than one year. Column total exceeds 100% because most respondents used more than one format. Column total exceeds 100% because some respondents indicated more than one main objective. CAM indicates complementary and alternative medicine. Colleges of Osteopathic Medicine.10 With the help of these individuals, we determined whether CAM was being taught at their schools and, if so, obtained the names of faculty members who were involved with the teaching. One administrator reported that no CAM was being taught at his institution, but the other 18 schools we contacted directed us to instructors who taught CAM or had detailed knowledge about CAM topics in their schools curricula. A total of 25 instructors at 18 schools were sent coded surveys by US mail, fax, or . Reminders and a second copy of the survey were sent to all nonresponders after 3 to 4 weeks. Surveys were collected through April To enable direct comparisons between osteopathic and allopathic medical schools, we used the same survey instrument that was used to collect data for our previous report on CAM instruction at allopathic medical schools.7 This twopage survey consisted of nine questions with a check-box or fill-in-the-blank format. Space at the end was reserved for written comments or clarifications. Questions were asked about year of undergraduate medical curriculum in which course was taught; whether the course was required or elective; whether it was taught by a single instructor or multiple instructors; total hours scheduled for course ( 20, 20-60, , 100); name of sponsoring unit; whether CAM practitioners/prescribers were involved in teaching; instructional formats used (instructor lectures, guest seminars, group discussions, case studies, clerkships, Internet-based, or other); principal course objective (broad survey of CAM concepts, scientific evaluation of CAM s effectiveness, practical training in CAM techniques, or other); and specific topics covered and time devoted to each (selected from a checklist of 19 CAM topics with spaces for additional topics to be provided by the respondent if needed). The survey was designed to be completed in 5 to 10 minutes. 122 JAOA Vol 104 No 3 March 2004

3 70 60 Respondents Teaching Topic, % Acupuncture Herbs and botanicals Spirituality Dietary therapy Homeopathy Other CAM topics* Meditation Ethnomedicine Vitamins and supplements Naturopathy Biofeedback Guided imagery Massage therapy Hypnosis Therapeutic touch Chiropractic Aromatherapy Music therapy Reflexology Energy therapy Figure. Topics on complementary and alternative medicine taught at osteopathic medical schools, *Miscellaneous topics not listed, including osteopathic manipulative treatment, which was considered alternative by 16% of the respondents. Includes topics such as ayurveda, Chinese medicine (excluding acupuncture), and Native American medicine. Includes modes of therapy that use electromagnetic fields, such as magnet therapy. Results Of the 19 AOA-approved schools we contacted, 18 (95%) were offering some form of CAM instruction in the undergraduate medical curriculum. Of the 25 instructors who were sent surveys, all returned completed forms with specific information about CAM instruction at their schools. Thirteen of the schools had a single respondent, four of the schools had two respondents each, and one school had four respondents. From the 25 returned surveys, we assembled data regarding CAM-related courses taught at the 18 colleges of osteopathic medicine for whom we received responses. Table 1 summarizes the salient features of these courses. Two thirds (64%) of the respondents indicated that they taught a required course, with most of the remainder (28%) teaching an elective course. Our survey did not distinguish between courses that were devoted entirely to CAM and those that contained CAM components but were otherwise of a traditional nature (eg, lectures on herbal medicine in a pharmacology course). Most of the CAM-related courses were taught by teams and offered in the first or second year of medical school. Twelve percent of the courses were offered in the third or fourth year. Half of the courses devoted fewer than 20 contact hours to CAM instruction, but nearly one fourth devoted more than 60 hours (Table 1). Most (60%) courses were sponsored by clinical departments, and only 12% were sponsored by basic science departments. About one fourth of the respondents did not specify a sponsoring unit, which may indicate the involvement of several units in a multidisciplinary course. Lectures by faculty instructors were the predominant means of CAM instruction (Table 1). Guest speakers, group discussions, and case studies were substantially used as well. Eight percent of instructors taught CAM during third- or fourth-year clerkships. The Internet was used to deliver CAM material by 16% of the instructors. Sixty percent of the respondents reported that the principal objective of their course was to provide a broad survey of CAM and introduce students to a spectrum of topics related to alternative medical practices (Table 1). Practical training in JAOA Vol 104 No 3 March

4 Table 2 Major Differences Between Courses in Complementary and Alternative Medicine Taught at Osteopathic and Allopathic Medical Schools Osteopathic Allopathic Medical Medical School School Respondents, % Respondents, %* Course characteristic Required course Taught in third or fourth year Basic science sponsorship 12 5 Group discussion format Clerkship-based format 8 23 Internet-based format 16 4 Topics addressed Meditation Massage therapy Hypnosis Therapeutic touch Chiropractic Energy therapy 4 12 *Data from Brokaw JJ, Tunnicliff G, Raess BU, Saxon DW. The teaching of complementary and alternative medicine in US medical schools: a survey of course directors. Acad Med. 2002;77(9): CAM indicates complementary and alternative medicine. the use of specific CAM treatments accounted for 20% of the reported course objectives. Few (12%) of the respondents considered a scientific evaluation of CAM s effectiveness to be a principal course objective. Nearly three fourths of the courses were taught by individuals identified as being CAM practitioners or prescribers of CAM modes of therapy. Of the 19 CAM topics listed in our survey, acupuncture and herbs and botanicals were clearly the most popular, each being cited by 68% of the respondents (Figure). Spirituality (56%), dietary therapy (52%), and homeopathy (48%) were the next most popular. The remaining topics ranged from 36% for meditation and ethnomedicine to 4% for energy therapy. Almost half (48%) of the respondents indicated that they taught CAM topics not included in our survey s checklist. These topics included CAM diagnostics and therapeutics, new age, hyperbaric oxygen therapy, integrative medicine, mind-body medicine, CAM and clinical reasoning, CAM and cultural considerations, and art therapy. For the purposes of this survey, osteopathic manipulative treatment (OMT) was not considered a CAM treatment modality. However, some respondents (16%) included OMT in their list of CAM topics taught. In these cases, OMT was relegated to other CAM topics, as no other suitable category existed. Not all respondents who taught a topic indicated their time commitment. Accordingly, there were too few data to accurately compute a median number of contact hours for each topic. Inspection of the data revealed that the amount of instructional time devoted to any given topic ranged from 15 minutes to 12 hours. For all topics combined (excluding OMT), the median number of contact hours per topic was 1.0 (n 87). For the most part, the CAM-related courses taught at osteopathic medical schools were similar to those taught at allopathic medical schools affiliated with the American Association of Medical Colleges.7 However, a few major differences were noted (Table 2). Differences were considered major if they were on the order of twofold or greater in magnitude. Compared to the courses at allopathic medical schools, those at osteopathic medical schools were more likely to be required than elective and less likely to be taught during third- or fourth-year clerkships. Basic science sponsorship was minimal in both settings, but somewhat more common in osteopathic medical schools. Whereas most of the courses at allopathic medical schools used group discussions, a much smaller proportion of those at osteopathic medical schools did so. However, use of the Internet for instructional purposes, though not substantial in either setting, was more common among osteopathic medical schools. The topical content of these courses varied (Table 2). The 124 JAOA Vol 104 No 3 March 2004

5 proportion of instructors at osteopathic medical schools who taught about meditation, massage therapy, hypnosis, or therapeutic touch was only about half that at allopathic medical schools. Chiropractic was included in relatively few courses at osteopathic medical schools (16%), but was a common topic in courses at allopathic medical schools (60%). Energy medicine was an infrequent topic at both osteopathic and allopathic medical schools, but was more frequently taught at allopathic medical schools. Among the remaining 13 CAM topics, there was less divergence and both types of medical schools presented similar profiles. Discussion The present survey and its analysis of CAM instruction at 18 osteopathic medical schools is an extension of an earlier study of CAM course offerings at 53 allopathic medical schools.7 Although the number of completed surveys was necessarily limited (n 25), we believe that our results offer a reasonably accurate snapshot of the current state of CAM instruction in US osteopathic medical schools. Because of the relatively small number of AOA-approved schools, we were able to make personal contact with an academic administrator at each institution who could help us locate CAM instructors with specific information. This approach enabled us to make direct comparisons with the data collected from CAM instructors at allopathic medical schools.7 Our results indicate that the form and content of CAM instruction at osteopathic medical schools are similar to those offered at allopathic medical schools. We found no evidence to suggest that CAM is more prevalent at osteopathic medical schools than allopathic medical schools. However, this conclusion is predicated on the assumption that OMT is not a CAM treatment modality. Not everyone would agree with this premise, including some osteopathic physicians. Sixteen percent of our respondents cited OMT as a CAM topic, which indicates a lack of consensus even among osteopathic physicians. The National Center for Complementary and Alternative Medicine at the National Institutes of Health considers osteopathic manipulative treatment to be CAM therapy and is currently funding several clinical trials of OMT.11 Osteopathic manipulative treatment and its underlying theory of somatic dysfunction stands as the principal (and perhaps only) inherent distinction between osteopathic and allopathic medicine.12 Some studies suggest that OMT use by practicing physicians is on the decline, particularly among recent graduates of osteopathic medical schools.13 This has serious implications for osteopathic medicine s uniqueness as a medical profession. Perhaps external validation from controlled clinical trials, such as those now being conducted under government auspices,11 will serve to reinvigorate OMT s position in osteopathic medical education and clinical practice. Although we found that CAM instruction at osteopathic and allopathic medical schools was on the whole similar, there were a few notable differences (Table 2). For example, courses with CAM content were twice as likely to be required at osteopathic medical schools than at allopathic medical schools. This may indicate a greater commitment to CAM education at osteopathic medical schools, but could just as easily reflect the incidental inclusion of CAM topics into several required courses of the traditional osteopathic curriculum. Another difference is that most CAM instruction at osteopathic medical schools occurred during the first 2 years, whereas CAM instruction during the third and fourth years was relatively uncommon. By contrast, the teaching of CAM at allopathic schools was substantial during the third and fourth years.7 In general, these data suggest that students at osteopathic medical schools are more likely to be exposed to CAM in required coursework during the preclinical part of their training, whereas students at allopathic medical schools tend to learn about CAM in elective coursework taken during the clinical years. Despite the dominance of the preclinical years in CAM instruction, the involvement of basic science departments at osteopathic medical schools was surprisingly meager, accounting for only 12% of the sponsored courses. An even smaller proportion (5%) of basic science sponsored courses was reported for allopathic medical schools.7 A related (and troubling) finding was that so few of the courses at either type of medical school emphasized a scientific approach to the evaluation of CAM s effectiveness. Only 12% of the respondents at osteopathic medical schools and 18% of respondents at allopathic medical schools7 considered a review of the scientific literature regarding CAM to be a major course objective. This may reflect the fact that most of the CAM instructors were also CAM practitioners, who may lack a critical perspective about the treatments they use and presumably believe in. As the popularity and availability of alternative modes of therapy continue to grow, it becomes increasingly important that physicians-in-training appreciate the value of scientific evidence in evaluating claims of therapeutic efficacy. Basic science faculty with expertise in experimental design and statistical analysis of data should be enlisted to help impart a critical balance to the CAM instruction. As was true of CAM instruction at allopathic medical schools, the CAM topics taught at osteopathic medical schools encompassed a diverse collection of unorthodox beliefs and practices. The five most prevalent topics acupuncture, herbs and botanicals, spirituality, dietary therapy, and homeopathy were among the top seven topics taught at allopathic medical schools.7 Likewise, the four least prevalent topics aromatherapy, music therapy, reflexology, and energy therapy were also the least prevalent topics at allopathic medical schools.7 In general, the emphasis given to a particular CAM topic was comparable between osteopathic and allopathic medical schools. However, six topics were considerably less prevalent among the osteopathic medical schools (Table 2). The most conspicuous of these was chiropractic, which was taught by JAOA Vol 104 No 3 March

6 60% of the respondents at allopathic medical schools,7 but by only 16% of respondents at osteopathic medical schools. This disparity may reflect the divergent yet related histories of osteopathic medicine and chiropractic. Both professions arose at about the same time and shared certain beliefs, most notably in the therapeutic value of spinal manipulation.12 But here the similarity ends. The two systems took different evolutionary pathways after their establishment. Whereas osteopathic medicine developed into a science-based medical profession and moved closer to allopathic medicine in theory and practice, chiropractic retained much of its initial orientation and remained focused on spinal manipulation therapy. Nevertheless, the two professions are often confused with each other in the public s mind, and chiropractic is the better known of the two.14 There is an understandable desire by osteopathic physicians to distinguish themselves from chiropractors, which may account for some of the respondents ambivalence toward teaching chiropractic. Allopathic physicians tend to view osteopathic medicine and chiropractic as similar alternative modes of therapy, holding neither in particularly high regard.15 The differences exhibited for the other five CAM topics were less dramatic and may reflect the individual interests of our small number of respondents compared to the larger data set from allopathic medical schools (n 73).7 Summary We found that the typical CAM course taught at colleges of osteopathic medicine was a team-taught, required course sponsored by a clinical department. It was most likely to be taught in the first 2 years of medical school, have fewer than 20 contact hours, and use lectures as the primary instructional format. The course was probably taught by proponents of CAM modes of therapy who might not be disposed to impart a critical, evidence-based perspective. It was most likely a survey course designed to introduce students to a broad array of popular CAM topics, such as acupuncture, herbs and botanicals, spirituality, dietary therapy, and homeopathy. Other than the notable differences discussed previously, these course descriptors are similar to those reported for CAM courses at allopathic schools.7 References 1. National Center for Complementary and Alternative Medicine. What is complementary and alternative medicine (CAM)? Available at: Accessed February 10, Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. Unconventional medicine in the United States: prevalence, costs, and patterns of use. N Engl J Med. 1993;328(4): Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, : results of a follow-up national survey. JAMA. 1998;280(18): Straus SE. Complementary and alternative medicine: challenges and opportunities for American medicine. Acad Med. 2000;75(6): Carlston M, Stuart MR, Jonas W. Alternative medicine instruction in medical schools and family practice residency programs. Fam Med. 1997;29(8): Wetzel MS, Eisenberg DM, Kaptchuk TJ. Courses involving complementary and alternative medicine at US medical schools. JAMA. 1998;280(9): Brokaw JJ, Tunnicliff G, Raess BU, Saxon DW. The teaching of complementary and alternative medicine in US medical schools: a survey of course directors. Acad Med. 2002;77(9): Park CM. Diversity, the individual, and proof of efficacy: complementary and alternative medicine in medical education. Am J Public Health. 2002; 92(10): Lesho EP. An overview of osteopathic medicine. Arch Fam Med.1999; 8(6): American Association of Colleges of Osteopathic Medicine. Websites of osteopathic medical colleges. Available at: Accessed January 11, National Center for Complementary and Alternative Medicine. Osteopathic manipulation clinical trials. Available at: Accessed March 1, Howell JD. The paradox of osteopathy. N Engl J Med. 1999;341(19): Johnson SM, Kurtz ME, Kurtz JC. Variables influencing the use of osteopathic manipulative treatment in family practice. J Am Osteopath Assoc. 1997;97(2): Gevitz N. Visible and recognized: osteopathic invisibility syndrome and the 2% solution. J Am Osteopath Assoc. 1997;97(3): McPartland JM, Pruit PL. Opinions of MDs, RNs, allied health practitioners toward osteopathic medicine and alternative therapies: results from a Vermont survey. J Am Osteopath Assoc. 1999;99(2): JAOA Vol 104 No 3 March 2004