Survey of First and Second Year Medical Students Familiarity and Comfort with Complementary and Alternative Medicine

Transcription

1 Complementary and Alternative Medicine Survey of First and Second Year Medical Students Familiarity and Comfort with Complementary and Alternative Medicine Rebecca Brundin-Mather, MASc Vishal Avinashi, MD Marja Verhoef, Ph.D. Abstract Complementary and alternative medicine (CAM) is widely used throughout Canada, yet most physicians know little about these therapies and may find it difficult to talk to their patients about their use. As part of a national initiative to develop curricula on CAM for undergraduate medical education programs, an anonymous questionnaire was distributed to all first and second year medical students in Canada in order to assess their comfort with, beliefs about, and exposure to CAM. The average response rate was 44%, ranging from 4% to 79% across schools. Although 89% of all students reported that they would ask their future patients about CAM, only 45% indicated that they currently felt prepared to discuss CAM with patients or colleagues. Eighty-four perecent agreed that CAM research must meet the same standards as conventional research to be valid and acceptable, but only half agreed that a therapy that has not been proven by western science should not be recommended to patients. Across schools, students agreed that there is a need for increased CAM curricula in UME, yet only 25% of respondents reported receiving CAM education (range from 1% to 84%). Results of this questionnaire highlighted the interest and expectation of pre-clerkship medical students in Canada to learn about CAM and to apply this knowledge in their future practice. Introduction Complementary and alternative medicine (CAM) is a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine. 1 Examples of CAM are acupuncture, ayurveda, chiropractic, natural health products, and homeopathy. Although individuals commonly report wanting to talk to their physicians about the use of CAM, they tend not to do so. 2-5 Reasons for this lack of communication include physicians not asking patients about their CAM use as well as patient perceptions that (a) their physician will not approve of their CAM use, (b) their CAM use is not relevant information for their physician, and (c) their physician lacks knowledge about CAM. Although studies do show that knowledge about CAM is lacking amongst practicing physicians, there is ample research that shows that physicians are interested in learning more about CAM, including wanting more attention paid in undergraduate, graduate, and continuing education courses. 6-9 Moreover, the public s demand for CAM has spurred some physicians to make referrals to complementary and alternative practitioners, to provide these services, and to take the initiative to become educated regarding the safety, efficacy and assumptions of CAM approaches. 3,10,11 Medical student surveys also indicate that students (1) lack knowledge about CAM, (2) want to become more familiar with CAM in their undergraduate medical education, but (3) become less interested in knowing about CAM as they progress through medical school. 12,13 In 1999, Ruedy et al., reported that 81% (13/16) of Canadian medical schools included CAM in their curriculum. 14 However, they provided few details in their study about the depth and breadth of CAM inclusion in undergraduate medical education (UME) programs. We know from our own research, conducted as part of a large-scale effort to generate and collate CAM curriculum for UME programs, that there is tremendous variability across Canadian medical schools in CAM content. 15,16 For those schools that offer some CAM teaching, integration into the existing curriculum is limited with most teaching being add on and elective. At the same time, there is an identified need and a strong desire for CAM education that focuses on definitions, evidence, safety, doctor-patient communication, and attitudes/respect. Many stakeholders are involved in the process of changing medical school curriculum including deans, curriculum committees, administrators, teaching faculty, and medical students. While there may have been brief local surveys of medical students, to date there has not yet been a national survey of medical students in Canada about CAM. Consequently, we surveyed pre-clerkship medical students in the 16 Canadian schools about CAM in order to document student interest and involvement with CAM, and to identify specific CAM curricular needs in this area. To this end, we asked medical students about their: 1 comfort in discussing CAM, 2 general beliefs about CAM research and evidence, and 3 exposure to, and opinions about, CAM education in UME. volume 83, number 1, December

2 Figure 1. Survey response rate of first and second year medical students. Materials and Methods Participants There were approximately 3500 first and second year medical students attending Canada s 16 medical schools at the time of the survey. To facilitate distribution of the questionnaire, school representatives were recruited from the Canadian Federation of Medical Students (CFMS) and the Fédération des étudiants medicines du Québec (FEMQ). Given that medical students are typically oversurveyed and less likely to respond to questionnaires left in their mail box, each school representative was asked to hand out the questionnaire to first and second year students at the end of a mandatory class. As this was not possible for all third and fourth year classes, they were excluded from the sample population. Participation in the study was voluntary. The questionnaire was anonymous and took approximately 5 minutes to complete. As an incentive, a cash prize of $200 was offered to the school with the highest percentage of completed questionnaires. Questionnaire Questions on the two page survey were predominantly drawn from an unvalidated 10-item questionnaire developed at the University of Maryland Complementary Medicine Program. 17 The Complementary Therapies Questionnaire was designed for medical students, and serves as a course evaluation tool as well as a general survey of knowledge and attitudes. The Maryland questionnaire was modified by changing the three-category format (Yes, No, and Don t Know) to a four category format. In addition, one question on licensing was modified to reflect the Canadian context, and items added that asked more detailed feedback about CAM education in UME. The questionnaire was translated from English to French in order to survey students attending Université de Sherbrooke, Université Laval, and Université de Montréal. The questionnaire was reviewed by several members of the CAM in UME project advisory group prior to being distributed. Descriptive analyses were conducted on all the questions. Chi square analyses and t-tests were conducted to compare first and second year responses to each question. Although between-school differences were not statistically analyzed due to the extreme variability in response rate across schools and the lack of homogeneity of variance within some schools, some school differences will be reported where relevant. This study was approved by the University of Calgary Conjoint Health Research Ethics Board and the Saskatchewan Behavioural Research Ethics.* Results All 16 medical schools agreed to participate in the survey. The mean response rate was 44%, though the response rate varied As Dr. Avinashi was a medical student at the University of Saskatchewan at the time of our ethics submission. Thus, as a co-investigator on this project, we required ethics approval from his home institution. 54 University of Toronto Medical Journal

3 Table 1 Medical students ratings of their comfort with CAM and beliefs about CAM research. Survey Question Strongly Disagree Disagree Agree Strongly Agree When I am in practice, I will always ask my patients 1% 9% 52% 37% about their use of CAM When I am in practice, I think I will feel comfortable 1% 4% 49% 45% asking patients about their use of CAM I feel prepared to discuss one or more forms of CAM 14% 31% 36% 17% with patients or colleagues CAM research must meet the same standards as 2% 13% 46% 38% conventional research to be valid and acceptable Current scientific evidence support CAM is scanty and poor 3% 31% 51% 12% Should not recommend a therapy that is not proven 5% 39% 42% 13% effective by western science across schools from 4% at the University of British Columbia to 79% at Memorial University of Newfoundland (Figure 1). In addition to low response rates, not all schools returned surveys from both 1 st and 2 nd year students. Of the 1641 students who responded, 716 were first year students and 925 were second year students. There were no statistically significant differences between first and second year student responses to survey questions. General Knowledge First and second year medical students estimated on average that 44% of the Canadian population uses CAM, and that 52% of patients do not tell their physician that they use CAM. Most students reported that between 2 and 4 of the 13 provincial and territorial licensing authorities in Canada have policies addressing physician practice of CAM and/or physician referral to CAM practitioners. Comfort with CAM and General Beliefs about CAM Evidence Seventy-five percent of all first and second year medical students agreed or strongly agreed that patients should first see a medical doctor before undergoing CAM treatment(s), and 92% felt that medical licensing boards should have written policies addressing physician practice of CAM and/or physician referral to CAM practitioners. Table 1 presents the total student response rate on questions assessing their comfort with CAM and their beliefs about CAM evidence. There was generally greater dispersion of scores across the four response categories on questions current scientific evidence supporting CAM is scanty and poor, should not recommend a therapy that is not proven effective by western science, and on ratings of feeling prepared to discuss CAM with patients or colleagues. Across schools, the aggregate agreement score varied between 30% and 66% on these questions, with the greatest range on feeling prepared to discuss CAM (from 23% at McMaster University to 89% at Université de Laval). Table 2 presents the results of student ratings of the safety and effectiveness of nine CAM areas. The question format permitted students to check each therapy as (a) safe, (b) unsafe, (c) effective, (d) ineffective, and/or (e) one that they personally had used. With Table 2 Medical students ratings of the safety, effectiveness, and personal use of CAM Complementary Therapy Safe Unsafe Effective Ineffective Personally Use Massage 82% 2% 69% 7% 33% Prayer/Spiritual Healing 76% 2% 44% 22% 14% Acupuncture 72% 10% 56% 12% 11% Mind-Body Therapies 66% 4% 35% 22% 5% Vitamins 65% 15% 57% 13% 34% Hypnosis 53% 12% 26% 33% 2% Homeopathy 48% 16% 20% 40% 9% Chiropractic 42% 37% 47% 18% 19% Herbs 35% 38% 36% 24% 14% volume 83, number 1, December

4 A lack of preparation and/or knowledge about CAM is not surprising given that only a quarter of students reported receiving formal CAM education. At the same time, a comparison of students who reported receiving formal CAM and those who did not shed little light on whether CAM education impacts on students comfort with CAM or perceptions and knowledge of CAM. Given that there may also be a social desirability bias on the part of some participants, future research should examthis approach, the percentages in safe and unsafe and effective and ineffective may not add up to 100. Although not a one-to-one correspondence, the therapies most frequently rated as safe and effective were also least likely to be rated as unsafe and ineffective. Massage was most frequently rated by students as safe and as effective, herbs as unsafe, and homeopathy as ineffective. Fifty-nine percent of students reported having used some CAM personally, most frequently citing vitamins and massage. Exposure to, and opinions about, CAM in UME Eighty-seven percent of all students agreed or strongly agreed that there is a need for increased CAM curricula in undergraduate medical education. Across schools, the combined percentages ranged from 71% at UBC to 96% at Dalhousie. Overall, 25% of participants, 18% of first year and 30% of second year, reported receiving some formal CAM education. Yet the variability between schools was extreme with reports ranging from 1% at Université de Sherbrooke to 84% at University of Western Ontario (see Table 3). Of the 430 students who reported receiving CAM education, 73% agreed that this education was useful in making them feel more comfortable with discussing the topic with patients, but only 46% were satisfied with the content and delivery of the instruction. Table 3 Medical students reports of having received CAM education School Yes No Don t Know Western Ontario 84% 15% 2% Saskatchewan 54% 44% 3% Memorial 49% 47% 4% Manitoba 46% 49% 5% McGill 36% 60% 4% Queen s 21% 74% 6% Dalhousie 19% 80% 1% Montreal 16% 81% 3% Laval 10% 88% 2% McMaster 9% 90% 1% Alberta 9% 91% 0 Toronto 8% 92% 0 Ottawa 7% 91% 2% Sherbrooke 1% 99% 0 Explorative analyses on the sub samples of students who had received CAM education and those who did not produced some interesting results. In some schools, such as the Université de Sherbrooke where essentially no students reported receiving formal CAM education, 85% of students agreed or strongly agreed that they felt prepared to discuss CAM with patients and colleagues. Ninety-four percent of students who had not received any education in CAM agreed that they would always ask their patients about CAM and would feel comfortable doing so. There were no significant differences between these two groups in their ratings of feeling prepared to discuss CAM. Table 4 presents medical student ratings of the usefulness of seven teaching methods in helping prepare them to advise patients about CAM. The top two teaching methods that students rated as useful or very useful were lectures and textbook readings, while using CAM to promote one s own health was most frequently reported as somewhat useful or not at all useful. Discussion and Conclusion The push for increased curriculum about complementary and alternative medicine in undergraduate medical education is not new. In many medical schools, medical students have, in fact, been the dominant driving force of curriculum. 15 This questionnaire was the first national survey of Canadian medical student s attitudes and beliefs about CAM as well as opinions of CAM education in UME. Although our response rate was low in some medical schools, the results mirror similar surveys in the published literature. There is clearly a willingness on the part of first and second year medical students to discuss CAM with their patients. However, whether this positive attitude remains throughout medical school and even residency cannot be answered in this study. There is some evidence in the literature to suggest that as medical students progress through their training, they become more skeptical towards CAM. 13 A more inclusive cross-sectional design or a longitudinal design that surveys students at multiple time periods throughout their training would provide important information in this area. Although the students in this survey know the prevalence of CAM use in Canada and the average rate of non-disclosure of CAM use to physicians, they appear to lack knowledge about the growing evidence base on CAM therapies. There is perhaps greater caution on questions requiring more specific knowledge of CAM research with 84% of all medical students agreeing or strongly agreeing that CAM research must meet the same standards as conventional research to be valid, and only 55% agreed or strongly agreed that a therapy that is not proven by conventional standards should not be recommended. Five percent of all participants (7% of first year and 4% of second year) did not attempt to assess the safety and effectiveness of the nine complementary therapies, quite possibly because they did not feel that they had the knowledge to rate the therapies. Certainly, there were many students, particularly in some medical schools, who reported that they did not currently feel prepared to discuss CAM with patients or with colleagues. 56 University of Toronto Medical Journal

5 Table 4 Medical students ratings of the usefulness of different teaching methods in helping prepare them to advise patients about CAM Not at all Useful Somewhat Useful Useful Very Useful Lectures 3% 14% 54% 27% Hands on experience with CAM and patients in clinical settings 5% 17% 41% 32% Observations of CAM practitioners 7% 20% 40% 28% Articles on clinical trials of CAM 4% 25% 43% 24% Case-base learning 7% 24% 45% 21% Textbook readings 9% 45% 35% 6% Using CAM to promote my own health 23% 36% 26% 9% ine the nature and duration of CAM education in order to draw more solid conclusions. CAM in UME It is encouraging that 87% of students who responded to this questionnaire see a need for increased CAM in UME. Furthermore, this study provides insight into teaching methods that may best impact student learning about CAM. Although lectures are rated as useful by most students, other more experiential approaches that may make a more lasting impact in acquired knowledge, skills, and attitudes also appear to be desirable. In responding to suggestions for CAM-related topics to include in UME, many students commented that education about CAM should be evidence-based. Forjuoh et al. reported initial success with teaching medical students about CAM using evidence-based medicine principles as a vehicle. 18 This approach served two important UME learning objectives including (1) how to read, understand, and appraise the medical literature, and (2) knowing about CAM. Folding CAM into a more mainstream concept such as evidence-based medicine may also ease its integration into undergraduate medical education programs. While the response rate was too low in some schools to generalize to all first and second year medical students, it is apparent that the majority of students who responded to this survey are interested in knowing about CAM and expect to receive this education during their undergraduate training in order to discuss it with patients. Within the past five years there has been an increase in CAM curriculum development in medical schools across Great Britain, 19,20 the European Union, 21 the United States, 22,23 and Canada. 16 Such curriculum changes are partially based on the belief that doctors must have an understanding of all the health services their patients may be accessing, particularly in order to appropriately assess and respond to potential interactions between various health treatments. The results of this survey provide further support from an important stakeholder group that medical schools in Canada must continue to work to integrate CAM into UME. Acknowledgments We wish to acknowledge the assistance of the school representatives to the Canadian Federation of Medical Students and the Fédération des étudiants medicines du Québec who distributed and collected the questionnaires on our behalf. This study was made possible through a grant from the Canadian Interdisciplinary Network for Complementary & Alternative Medicine Research. References 1. National Center for Complementary and Alternative Medicine. Bethesda: National Institutes of Health. Get the facts: What is complementary and alternative medicine (CAM)? [updated 2005 Jul 12; cited 2002 Oct 6]. Available from: 2. Ramsay C, Walker W, Alexander J. Alternative medicine in Canada: Use and public attitudes. Public Policy Sources. 1999; 21: Astin JA, Marie A, Pelletier KR, Hansen E, Haskell WL. A Review of the incorporation of complementary and alternative medicine by mainstream physicians. Arch Intern Med. 1998; 158: Sibinga EM, Ottolini MC, Duggan AK, Wilson MH. 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In: Proceedings from the Evaluation Conference for CAM CurriculumProceedings of a working conference on evaluation of CAM curricula June 17-18, Ann Arbor, US. Michigan: University of Michigan; 2002., Ann Arbor 18. Forjuoh SN, Rascoe TG, Symm B, Edwards JC. Teaching medical students complementary and alternative medicine using evidence-based principles. J Altern Complement Med. 2003; 9: Morgan D, Glanville H, Mars S, Nathanson V. Education and training in complementary and alternative medicine: A Postal survey of UK universities, medical schools and faculties of nurse education. Complement Ther Med. 1998; 6: Owen DK, Lewith G, Stephens CR. Can doctors respond to patients increasing interest in complementary and alternative medicine? BMJ. 2001; 322: Barberis L, De Toni E, Schiavone M, Zicca A, Ghio R. Unconventional medicine teaching at the Universities of the European Union. J Altern Complement Med. 2001; 7: Wetzel MS, Eisenberg DM, Kaptchuk TJ. Courses involving complementary and alternative medicine at U.S. medical schools. JAMA. 1998; 280: Maizes V, Schneider C, Bell I, Weil A. Integrative medical education: Development and implementation of a comprehensive curriculum at the University of Arizona. Acad Med. 2002; 77: volume 83, number 1, December