Edinburgh Medical School – 1f
Complementary and Alternative Medicine in the
undergraduate medical curriculum: a needs analysis
Karen Simpson, Janet Skinner, Allan Cumming
Medical Teaching Organisation, College of Medicine and
Veterinary Medicine, University of Edinburgh, Teviot Place,
Edinburgh EH8 9AG
With the growing popularity of Complementary and
Alternative Medicine (CAM) there is increasing pressure to
include this in the undergraduate medical curriculum. We
conducted a local needs analysis in Edinburgh for the
integration of CAM into the curriculum.
The needs analysis gathered quantitative and qualitative data.
An initial literature review and focus group discussions
revealed the broad need for change. 1,714 medical students
and members of teaching staff were surveyed. A seminar was
held and 4 strategic approaches to CAM in the curriculum
were developed. These strategies were used as the basis for a
modified Delphi process involving staff. Results of this
process were used to generate overall aims and strategy
regarding CAM in the curriculum.
The needs analysis revealed general overall support for
integration of CAM into the curriculum, but with concerns
about issues of efficacy, credibility and regulation. Teaching
staff were largely in favour of providing students with a broad
familiarisation with CAM, using an evidence and efficacybased approach to teaching.
Our results support the careful integration of CAM into the
undergraduate medical curriculum.
Integrating Complementary and Alternative Medicine into the
Undergraduate Medical Curriculum
Report of the Edinburgh Needs Analysis
January 2003
Janet Skinner
Fellow in Medical Education
College of Medicine and Veterinary Medicine
The University of Edinburgh
Medical School
Teviot Place
Edinburgh
EH8 9AG
2
Contents
Introduction
3
Complementary Medicine in Undergraduate Medical Education
3
Needs Analysis
4
Literature Review
4
Focus Group Discussions
4
Medical Student and Faculty Questionnaires
5
Questionnaire Results
5
Summary of Results
8
Strategies for Integrating Complementary Medicine into the Curriculum 8
Modified Delphi Process
8
Summary of Results of Needs Analysis
9
References
10
APPENDIX 1 Faculty Questionnaire
12
APPENDIX 2 Strategies
14
Introduction
Recently there has been a massive growth in the use of Complementary and Alternative
(CAM) therapies by patients, with 30% of the UK population using CAM in 1993, and
spending 1 million pounds (1,2,3). In the USA patients are more likely to consult a CAM
practitioner than a primary care physician (4). This growth in the use of CAM has lead to
increasing integration of CAM and conventional medicine, with up to 40% of GP practices in
the UK offering some CAM services (5).
This has lead to increasing calls for the formal inclusion of CAM in the undergraduate
medical curriculum from influential bodies such as the House of Lords and the General
Medical Council (GMC) (5,6). In 1999 the House of Lords Select Committee on Science and
Technology published a report on complementary medicine recommending that “every
medical school ensures that all their undergraduates are exposed to a level of CAM
familiarisation that makes them aware of the choices that their patients might make” (6).
Within this report they also categorised complementary medicine into groups, group 1
therapies are those “professionally organised alternative therapies”, and consist of:
Acupuncture, chiropractic, herbal medicine, homeopathy and osteopathy (6). In 2002 the
GMC published Tomorrow’s Doctor’s which states doctors must be “ aware that many
patients are interested in and choose a range of alternative and complementary therapies.
Graduates must be aware of the existence and range of such therapies, why some patients use
them, and how these might affect other types of treatment that patients are receiving” (7)
Complementary Medicine in Undergraduate Medical Education in the United Kingdom
The Education committee of the General Medical Council, under the chairmanship of
Professor Sir Graham Catto, conducted inspections of the United Kingdom’s undergraduate
medical curricula between 1998 and 2001. One aspect that was addressed was the inclusion of
CAM as part of their undergraduate programmes. The current situation was found to be
variable. Of 21 Medical Schools: 4 had no CAM in the curriculum, 10 offered optional or
elective topics, and only 7 had CAM as part of the core curriculum (8).
In Edinburgh CAM was not formally included in the curriculum, but students were given
informal, opportunistic exposure within the various subjects, and options or Special Study
Modules were intermittently available for interested students. The GMC report on the
Edinburgh medical curriculum was somewhat critical of the approach to CAM and they
“would encourage the faculty to review its approach to complementary medicine and to
explore ways of providing its students with more opportunity to learn about treatments that do
not conform to conventional practice, so that they are as informed about these as their future
patients” (8).
In Edinburgh this GMC report has proven to be a powerful driving force for change within
the Medical Faculty, but there is also a great deal of resistance to change within a University
that has a strong research background. The approach that was taken by the Faculty was to
commission a needs analysis on integrating CAM into the Edinburgh curriculum, and to
develop a strategy to meet this need. This needs analysis would focus on various stakeholders,
including students and staff.
Needs Analysis
A needs analysis was designed to determine the need for intervention or reform within the
curriculum. By taking a research based approach to the needs analysis it was hoped that
effective solutions or strategies could be developed. Both problems and solutions would be
generated, making change more likely to succeed. Quantative data was collected in the
form of questionnaires and qualitative data was collected from focus groups, a seminar
and questionnaire comments. The second stage of the needs analysis would employ the use
of a modified Delphi-process to try to develop consensus on a strategy for integrating
CAM into the curriculum (9).
Literature search
An initial extensive literature search was carried out analysing the current status of CAM in
medical education in the United Kingdom and worldwide. Much of the literature that does
exist relates to the optional or student-selected components, such as Owen et al’s description
of the Southampton innovative multi-professional special study module on complementary
medicine (10). Bryden also describes a special study module at the Glasgow homeopathic
hospital that “revisits basic assumptions” (11). There is little literature on the core curriculum,
but Berman discusses in a BMJ editorial the need to “clearly define educational goals”, in
2001 (12).
Within the literature from America there has been more debate about the role of CAM in
medical education, particularly the role of integrated medicine (13,14). In 1997 nearly 75% of
American Medical Schools were offering some instruction in CAM, but only 40% as part of
the core curriculum. (15,16). A survey by Reudy et al of Canadian medical schools revealed
that acupuncture and homeopathy were generally taught, but that a “general overview of
CAM should be given within health care belief systems” (17). Sampson discusses the need for
CAM to be explored through critical appraisal rather than advocation within the
undergraduate curriculum (18).
Focus Group Discussions
Introductory focus group discussions were held and revealed the wide spectrum of
attitudes among staff toward incorporating CAM into the medical core curriculum. It was
agreed that CAM should be part of the optional, or elective curriculum, and that the needs
analysis would concentrate primarily on the core curriculum, as the recommendations
from the GMC and House of Lords incorporated all students.
5
It was decided that the initial needs analysis should focus on- should CAM be incorporated
into the core curriculum: if so to what extent, in what format, what therapies should be taught,
and who should teach them? Initial questionnaires were designed to address these issues.
Medical Student Questionnaire
A questionnaire was constructed to examine student attitudes toward the integration of
CAM into the undergraduate curriculum. This was in the form of a standard 5-point Likert
rating scale (19). It was distributed to all 834 students of years 1 to 4 of the MBChB
Curriculum, through the Edinburgh Electronic Medical Curriculum (EEMeC) in
2001(20). Participation was anonymous and voluntary and there were no incentives for
the students to complete the questionnaire. All the students sampled were from the new
Vision 2000 Edinburgh Curriculum.
Faculty Questionnaire
After modification, the questionnaires were distributed by post to all 880 members of the
Board of Studies. The Board of Studies (BOS) consists of all members of staff who have a
teaching contract with the Faculty of Medicine, and consists of both clinicians and scientists.
The Board of studies questionnaire can be found in Appendix 1. The questionnaires included
a covering letter from the Associate Dean and a return envelope. No reminders were sent.
Results of Initial Questionnaires
An excellent response to the questionnaires was obtained from both students and staff. From
the students 387 electronic questionnaires were completed on-line from a possible 834
students (46% response rate), 152 from year 1, 107 from year 2, 83 from year 3 and 47 from
year 4. In terms of the Board of Studies, 450 completed questionnaires were returned by post
from a possible 880 members of staff (51% response rate).
In general terms the majority of both staff and students agreed or strongly agreed that CAM
should be in the curriculum (75% of staff and 90% of students), with 40% of staff and 56% of
students agreeing it should be in the core curriculum. Nevertheless only a small number of
staff and students agreed there should be a core module on CAM (30% and 19%
respectively).
6
Both groups were asked about teaching strategies: staff were in favour of case-based learning
approaches (63%), compared with the majority of students who were in favour of the use of
Computer-assisted learning packages (64%).
The most marked difference between the 2 groups was the question of whether or not an
evidence-based approach should be taken to exploring CAM, 83% of staff compare with only
40% of students agreed with this approach (Figure1).
There was no clear agreement from either group as to whether CAM should be vertically
integrated into the curriculum, or become part of the portfolio of work that students submit.
Staff were asked who should teach core content and 60% agreed that it should be faculty or
clinicians, with only 30% agreeing that CAM therapists should teach. They were also asked
which CAM therapies should be taught about, 50% said only those therapies with supporting
evidence and 43% said regulated therapies only (Figure 2).
200
180
160
140
120
No. 100
BOS
80
Stud
60
40
20
0
SA
A
U
D
SD
Responses
Figure 1 Should CAM be explored through an evidence-based medicine approach?
7
Figure 2 What therapies should be taught about?
The staff were asked about the depth of knowledge that students should possess about
CAM therapies, in terms of yes /no responses (Figure 3). Virtually everyone agreed that
students should know that CAM exists, and should know a small amount about a few
therapies. They disagreed that students should know a few therapies in detail, but the
majority of staff thought that students should know a small amount about many CAM
therapies. Staff did not think they should possess a large knowledge base about a broad
range of CAM therapies, and virtually everyone agreed that students need not possess
practical skills in CAM.
Figure 3 How much should students know about CAM therapies?
160
140
120
therapies with evidence of efficacy
100
No.
80
therapies with no supporting evidence
60
regulated therapies only
40
20
0
SA
A
U
D
SD
Responses
8
it exists
little about a few
few in detail
NO
YES
little about many
lot about many
practical skills
0
100
200
300
400
500
Qualitative Data From Questionnaires
Student Comments
Comments were obtained from 50 students with 70% displaying a positive attitude towards
the integration of CAM into the curriculum. Several students stated that CAM should be
available as an Intercalated Honours course and there was general agreement that CAM
should be in the curriculum in some format. Themes included a “broader knowledge of
CAM” with “detailed options available”, and that doctors should be “equipped to give
informed advice.
Many students expressed concerns related to curriculum overcrowding and other topics
“being side-lined”, and that CAM should be taught at a “Post-graduate level”. There were
also concerns expressed regarding credibility and “fads in medicine”.
Board of Studies Comments
Comments were returned on 167 questionnaires (37% of returns) and there were several
trends. There were equal numbers of frankly positive or negative comments (33 each).
Positive comments related to being able to “give sensible advice” and that some knowledge of
a “broad range of CAMs is essential”. Negative comments related to credibility and
“quackery”, fears that CAM would be taught at the “expense of core subjects” with further
“overloading” of the curriculum. Many comments were not so polarised and 26 appeared to
be occupying a middle ground and talked of “raising awareness”. The biggest sub-group
related to the evidence-base for CAM (34 comments), strands that appeared from this group
included only teaching about “therapies with evidence”, or teaching students to be able to
“critically evaluate” the evidence. Other comments (41) related to individual CAM therapies,
9
including the “definition of alternative medicine”, holistic care, level of integration and the
optional curriculum.
Summary of Questionnaire Results
The questionnaires revealed an overall support for the integration of CAM into the
curriculum, with clear concerns expressed about curricular overload and effect on other
components of the curriculum. The staff of the Board of Studies were largely in favour of
an “evidence-based” approach to this, shown both through qualitative and quantative
data, but this was not shown by the students, who were against this approach.
Strategies For Integrating Complementary Medicine into the Curriculum
A seminar was held on the 25th June 2002 and the results of the questionnaires were
presented. Discussions were held with stakeholders and interested staff members, and used to
devise several strategies for the approach toward CAM in the curriculum. It was felt that the
evidence based approach that staff seemed to favour would not meet the recommendation of
being as informed as their future patients, and that an options only approach would not mean
that “all” students were familiarised. The group agreed that students should be given the skills
to allow them to make informed decisions. The strategies that were developed are
summarised in Figure4, and listed fully in Appendix 2.
Figure 4 Strategies for the approach to CAM in the curriculum
“As informed as their future patients”
“Evidence and efficacy”
“Illness behaviour and psychological aspects”
“Big 5 therapies”
10
Modified Delphi Process
The strategies were distributed again by post to the 880 members of the board of studies.
A modified Delphi process was carried out, in which they were asked to rate the strategies
in order of their preferred strategy (1=most preferable 4=least preferable). Rated
strategies were returned from 307 members of the board of studies (35%) and the results
are shown in figure. There was a preference from the Faculty for an “evidence-based”
approach (41% rated this strategy as most preferable). If the 2 top ratings are combined
then 67% rated “evidence and efficacy” and 59% rated “as informed as their future
patients”, as their top 2 choices.
Figure 5 Results of Strategy Rating by Board of Studies
140
120
100
80
No
Informed
60
EBM
40
Psych
20
Top 5
0
1
most pref erable
2
3
4
least pref erable
R at ing
Qualitative Data From Rating of Strategies
Comments were returned on 56 of the completed strategies (18%), again there were equal
numbers of positive and negative comments. Many related to the fact that the 4 strategies
were “not necessarily mutually exclusive”, but there should always be an “evidence-based
approach” and that it should be an “extremely small” part of the curriculum.
Summary of Results of Needs Analysis
The quantitative and qualitative data from the initial questionnaires and the rating of strategies
by Faculty have shown diverse views in terms of CAM in the curriculum, but with a general
overall support for the integration. Concerns were expressed in terms of efficacy, credibility
11
and regulation. Both staff and students expressed clear issues about further overloading of the
curriculum, or impact on other subject areas. Both through the questionnaire and the rating of
strategies, staff showed a clear support for an evidence-based approach to any course on
CAM.
Considering the results of the needs analysis and the powerful driving forces for change, it
was decided to develop an integrated CAM course that is based around strategies 1 and 2,
providing students with a broad Cam familiarisation, but with a strong evidence-based
perspective.
This needs analysis was funded by the Alexander Dykes Endowment Fund of the University
of Edinburgh
References
1. Zollman C, Vickers A. ABC of complementary medicine: Users and practitioners of
complementary medicine. BMJ 1999; 319(7213): 836-838.
2. Ernst E. The role of complementary and alternative medicine. BMJ 2000; 321(7269):
1133-1135.
3. Rampes H, Sharples F, Maragh S. Introducing complementary medicine into the
medical curriculum. J R Soc Med 1997:90:19-22.
4. Eisenberg DM, Davis RB, Ettner SL, Appel S, et al. Trends in alternative medicine
use in the United States, 1990-1997:results of a follow-up national survey. JAMA
1998; 280(18): 1569-1575.
5. Rees L, Weil A. Integrated medicine. BMJ 2001; 322(7279): 119-120
6. House of Lords Select Committee Report on Complementary and Alternative
Medicine, HMSO, 1999
7. Tomorrow's Doctors, recommendations on undergraduate medical education. 2002.
URL http://www.gmc-uk-org
12
8. GMC Review Reports on UK Medical Schools, URL http://www.gmc-uk.org
9. Stritter FT, Tresolini CP, Reeb KG. The Delphi technique in curriculum
development. Teaching and Learning in Medicine 1994; 6 :136-41
10. Owen DK, Lewith J, Stephens CR. Can doctors respond to patients’ increasing
interest in complementary and alternative medicine? BMJ 2001;322:154-8.
11. Bryden H Commentary: Special Study Modules and complementary and alternative
medicine-the Glasgow experience. BMJ 2001;322:157-8
12. Berman B. Complementary medicine and medical education. BMJ 2001;322:121-2
13. Capspi O, Bell IR, Rychener D et al. The Tower of Babel: Communication and
Medicine. Arch intern Med 2000;160:3193-5
14. Weil A. The Significance of Integrative Medicine for the Future of Medical
Education. American Journal of Medicine 2000:108;441-3
15. Carlston M. The Revolution In Medical Education: Complemenatry Medicine Joins
the Curriculum. Health Forum Journal 1998
16. Wetzel MS, Eisenberg MD, Kaptchuk TJ et al. Courses involving Complementary
and Alternative Medicine at US Medical Schools. JAMA 1998;280:784-7
17. Ruedy J, Kaufman DM, Macleod H. Alternative and complementary medicine in
Canadian medical schools: a survey. CMAJ 1999;160:816-7
18. Sampson W. The need for educational reform in teaching about alternative therapies.
Academic Medicine 2001;76:248-50
19. Oppenheim AN. Questionnaire design, interviewing and attitudinal measurement.
Continuum, 2001.
20. Edinburgh Electronic Medical Curriculum. URL http://www.eemec.med.ed.ac.uk/
13
Appendix 1 Board of Studies Questionnaire
Thank you for completing this questionnaire. Please circle the response that you feel is most
representative of your views on the statement given.
1
strongly agree
2
3
agree
undecided
4
5
disagree
strongly disagree
1. There should be no Complementary and Alternative Medicine (CAM) in the
undergraduate curriculum
1
2
3
4
5
2. Options/Special Study Modules should be available for those students who have an
interest in CAM
1
2
3
4
5
3. CAM should be taught as part of the core curriculum
1
2
3
4
5
4. Case-based learning scenarios that explores attitudes towards CAM should be
included in the curriculum
1
2
3
4
5
5. CAM should be explored through an evidence-based medicine approach
1
2
3
4
5
6. Students should submit and be assessed on their ability to critically appraise a
research paper based around an area of CAM
1
2
3
4
5
7. CAM should be taught through self-directed Computer Aided Learning (CAL)
packages.
1
2
3
4
5
8. All students should spend a session with an alternative medical practitioner
1
2
3
4
5
9. A core module on CAM should be created using some or all of the above formats
1
2
3
4
5
10. CAM should be incorporated into an already existing vertical theme in the curriculum
1
2
3
4
5
11. CAM itself should be developed into a vertical theme in the curriculum
1
2
3
4
5
12. Holistic Care encompassing both CAM and conventional medicine should be a
vertical theme
1
2
3
4
5
13. Students should be taught holistic care as part of core CAM content
1
2
3
4
5
4
5
14. CAM should be incorporated into the Student Portfolio
1
2
3
15. Students should be taught core material by CAM practitioners
1
2
3
4
5
16. Students should be taught core material by interested clinicians / Faculty
1
2
3
4
5
17. We should only teach about those CAM therapies that have evidence for their
efficacy
1
2
3
4
5
18. We should teach about CAM therapies that have no supporting evidence
1
2
15
3
4
5
19. We should only teach about CAM therapies that have a professional regulatory
system in place
1
2
3
4
5
In terms of teaching and learning CAM, students should (please circle Y or N as appropriate)
Know that CAM exists
Y/N
Be aware of some common CAM therapies
Y/N
Know about a small number of CAM therapies in some detail
Y/N
Know a small amount about a broad range of CAM therapies
Y/N
Have a broad knowledge of many CAM therapies
Y/N
Possess practical skills in the performance of CAM techniques
Y/N
Please list any further suggestions, views or comments here
16
Appendix 2 Strategies for integrating CAM into the curriculum
Please rate the strategies below in terms of your preference
1=most suitable
4=least suitable
Insert either 1,2,3 or 4 in the boxes on the right hand side of the page
Thank you for your help
“As informed as their future patients”
Outcome Students will be familiar with a range of complementary therapies, such that allows
them to be aware of the choices that their patients might make, and their reasons for making
them.
Overview Complementary medicine will be integrated throughout the curriculum and will be
mapped to existing curricular areas, where relevant. A variety of teaching methods will be
used including; case-based learning sessions (exploring patients’ expectations, attitudes and
informed advice), CAL packages, seminars involving CAM therapists and integration into the
Primary Care Modules
“Evidence and efficacy”
Outcome Students will be able to demonstrate their ability to appraise complementary
therapies in terms of evidence-base, concentrating on those therapies with evidence for
efficacy, but also understanding the different types of evidence there are.
Overview Students will be taught to evaluate CAM through EBM methods, including the
critical appraisal of CAM research papers. Small group sessions will be held discussing
different “types” of evidence and the difficulties in obtaining scientific evidence for CAM
therapies. The students will also spent small group sessions designing a clinical trial for a
CAM therapy.
“Illness behaviour and psychological aspects”
Outcome Students will be able to explain the reasons why patients seek complementary
therapies, including the importance of the therapeutic consultation, communication skills and
issues of compliance.
17
Overview Through a combination of role play and cased based learning, the assumptions that
patients have about complementary therapies will be explored. Students will submit a piece of
work on CAM “cases” and will be asked to consider psychological and holistic aspects to this
process.
“Big 5 Therapies”
Outcome Students will demonstrate a broad understanding of the 5 main complementary
therapies that have professional regulatory systems in place (House of Lords Group 1
therapies). This will include knowledge of evidence-base, indications and interactions.
Overview Under the theme of “therapeutics” students will learn about the big 5 therapies
(herbal medicine, acupuncture, chiropractic, osteopathy and homeopathy). Teaching will
include CAL packages, seminars involving CAM therapists and practical sessions
Please insert any comments below or overleaf
18
Integrating Complementary and Alternative
Medicine into the
Undergraduate Medical Curriculum
Proposal for an Integrated Course
January 2003
Janet Skinner
Fellow in Medical Education
College of Medicine and Veterinary Medicine
The University of Edinburgh
Medical School
Teviot Place
Edinburgh
EH8 9AG
19
Contents
Introduction
3
Mission Statement
3
Curriculum Review
4
Objectives
5
Content
7
Content Map
9
Integration
10
Educational Strategies
10
Teaching Methods
11
Assessment
11
Assessment Map
11
Study Guide
12
Learning Resources
12
Educational Climate
12
Course Management
12
Summary
13
References
13
Introduction
This paper describes a proposal for the integration of Complementary and Alternative Medicine (CAM) into
the Edinburgh Undergraduate Medical Curriculum. It follows on from a needs analysis commissioned by the
Faculty of Medicine that was conducted between February 2002 and October 2002. The results of the needs
analysis along with the powerful driving forces for change, particularly from the General Medical Council,
have been previously documented and are used as a basis for this description of the potential way forward.
The results of the needs analysis suggested that an “evidence-based” approach should be taken to providing
all students with a broad CAM familiarisation.
The model that is used as a basis for this curriculum planning exercise was described by Stilbeck and was
first used to plan and develop curricula within schools, and is show in Figure 1 (1). This document describes
the “goal formulation” and the initial “programme building stages” of developing a CAM curriculum.
Harden’s structure and guide for curriculum planning is also used as a basis for this document (2,3).
Figure 1 Malcolm Skilbeck’s model of curriculum planning.
Evaluation
Interpretation and
Implementation
Situational Analysis
Goal Formulation
Programme Building
Developing a Mission Statement
21
The results of the needs analysis were used to develop a statement of aims that details the overall
institutional philosophy or approach to CAM in the undergraduate curriculum. The mission statement is
divided into knowledge, skills, and attitudes, and consists of:

Knowledge
In order to participate fully in the process of patient care, students will be able to describe the therapeutic
choices, including complementary and alternative (CAM) therapies, that are available to patients. They will
be informed enough about CAM to be able to discuss these therapeutic choices with patients. They will
understand the importance of the potential interactions between CAM therapies and conventional medical
treatment. As part of an overall approach to evidence based practice within the curriculum, students will
learn to critically evaluate evidence for the efficacy of different forms of treatment, including CAM
therapies.

Skills
There will be no core requirement for students to possess practical skills in CAM therapies. Opportunities
will be provided within the Student-Selected Component (SSC) programme for interested students to
explore individual CAM therapies in more detail, in some cases to the level of developing practical skills.
There will be opportunities for students to explore communication and consultation skills through CAM.

Attitudes
Students will learn to respect the rights of patients to be fully involved in decisions about their care, and to
choose to use different forms of therapy and to attend a range of practitioners. They will understand the
reasons why patients choose to use non-conventional treatments. They will understand the importance of cooperation between the different individuals and agencies involved with patient care.
This mission statement was also kept within the philosophy of “The Scottish Doctor” which is a set of
learning outcomes, devised by the Scottish Dean’s Medical Curriculum Group, that relate to any graduate
from the Scottish medical schools (4). The outcomes for CAM are shown below:
Level 2 Outcomes for patient management
22
Level 3 Complementary therapies
Level 4 -Appreciation of what is available
-Outline of what is involved in most commonly practised therapies; how alternative
and conventional therapies may be combined
-Keeping an open mind and remaining non-judgemental
Curriculum Review
A detailed curriculum review was conducted to look at areas where CAM is already taught, and areas where
it could potentially be included. This was done by analysing and mapping existing study guides, the
Edinburgh Electronic Medical Curriculum (EEMeC) and through discussions with stakeholders (5).
Existing core curricular areas were scanty and consisted mainly of a lecture within ‘ Health and Society’
module in Year 1, term 1, as part of a series on health beliefs and why patients seek medical care.
In year 4 as part of a joint General Practice / Neurology / Psychiatry lecture week all students received a talk
from a medically qualified homeopath on the use of complementary therapies in chronic pain management.
It was also highlighted that CAM was taught informally at many points in the curriculum, but this was in an
opportunistic manner, not core, not detailed in the objectives of the courses or modules, and not assessed.
Objectives
The curriculum review highlighted many areas of the curriculum that CAM could be incorporated into,
without major restructuring, or loss of other core content. The results of the needs analysis and the mission
statement were used to devise specific objectives for the Edinburgh Undergraduate Medical Curriculum.
These are:
Knowledge
Discuss the reasons why patients choose to use complementary treatments or to consult with an alternative
practitioner
23
Describe the importance of psychological, spiritual and social issues in the management of patients
Describe how different members of the expanded health care team, including complementary therapists, can
play important roles in patient management
Describe the importance of osteopathy and chiropractic in managing musculoskeletal disorders, such as back
pain, including the efficacy of these therapies
Discuss the use of complementary therapies, particularly acupuncture in the management of chronic pain
Understand the importance, and potential seriousness, of interactions that can occur between complementary
therapies and conventional therapies. Know how to access information about these interactions.
Describe the use of herbal medicines in psychiatry, including the evidence-basis for these
Discuss the growing use of homeopathic medications in many medical conditions
Describe how complementary medicine fits with, and relates to, conventional medicine
Discuss the growing use of complementary therapies by Western populations
Discuss the use of complementary therapies within alternative healthcare systems, and relate this to your
Year 5 Elective
Skills
The ability to discuss therapeutic choices with patients, including complementary therapies
24
The ability to elicit a history of complementary therapy use during a patient consultation, including the
patient’s reasons for using them
The ability to critically appraise the evidence in support of efficacy of complementary therapies
Attitudes
An appreciation of the individuality of patients and that each patient has the right to be involved in decision
making about their treatment
An enthusiasm to learn from patients, all members of the primary healthcare team and other resources in the
community
Understand the importance of clear communication between different individuals involved in patient care
Understand the importance of the consultation with the complementary therapist, including the ‘therapeutic
touch’
Maintaining an open mind about alternative approaches to patient care
An appreciation that not all patients will disclose their use of complementary therapies to a conventional
practitioner, and reasons why this may be so.
Respect the rights of patients to choose different forms of therapy or to attend a range of practitioners
The content of the course
The process of curriculum review highlighted various interested stakeholders and meetings were held with
these Faculty members to generate ideas for course content that would meet the planned aims and objectives.
25
1. Pharmacology and Therapeutics Theme (Simon Maxwell)
The case for incorporating CAM into the core vertical theme of Pharmacology and Therapeutics was
discussed. The theme would become Pharmacology, Therapeutics and Complementary Medicine, or
‘Therapeutics’ alone. Developing a self-directed computer assisted learning package on complementary
therapies was discussed, and it was agreed that this was a long-term project that may require external
funding. There were clear advantages of including certain CAM therapies within this theme, particularly
Herbal Medicines and Homeopathy, including the importance of CAM/conventional medicine
interactions.
2. Portfolio Theme (Helen Cameron)
It was decided that it would be appropriate to incorporate CAM into the student portfolio of submitted
work that occurs throughout the undergraduate course, and includes cases and critical appraisal. It is a
way of bringing together several important topics that run throughout practice regardless of the
specialty. Complementary medicine would become one of the portfolio vertical themes; others include
disability, pain and evidence-based practice.
3. Year 1 Health and Society Module (Mike Porter)
The existing session on CAM was discussed and it was decided to expand on this and develop it into a
session on “why patients seek CAM therapies”. This 2 hour session would include an overview of CAM,
then talks from 3 CAM therapists, at least one of which would also be a be a doctor They would discuss
“why do patients come to see me?” It was also decided to include CAM within the Year 1 case-based
learning that centres on a patient with breast cancer and “talking with families” in term 2.
4. Year 3 Locomotor System Module (Rashid Luqmani)
The manipulative therapies (Chiropractic and Osteopathy) were discussed and it was decided that they
could be incorporated within the combined locomotor system module, particularly within the back pain
lecture and clinical case that all students undertake.
5. Year 4 General Practice Module (Karen Fairhurst)
It was decided to try and offer all students some practical exposure to CAM therapies within this
attachment. This would involve all students spending a half-day session with a CAM practitioner within
the local GP practices (50% offer some CAM services). This need not be a specific or particular therapy,
26
but would give the student some exposure to practical CAM. The existing chronic pain session would
continue but would focus primarily on the use of Homeopathy and Acupuncture.
6. Year 5 General Practice-Patient Management Module (Scott Murray)
Holistic aspects of CAM including, spiritualism and integrated health care were discussed and it was
decided that they could be included within the final GP attachment in year 5. Currently CAM is being
assessed within the patient management problems that the students submit. It was also discussed that it
may be more appropriate for practical sessions to occur in year 5.
Other second line stakeholders that meetings could be arranged with include:
Year 2 case-based learning
Year 3 Public Health and Epidemiology
Year 3 Evidence-Based Medicine
Year 4 Psychiatry
Year 5 Child Life And Health
Year 5 Anaesthetics
Medical Librarians
27
YEAR 1
YEAR 2
YEAR 3
YEAR 4
YEAR 5
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Critical
Psychological
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skills
health
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skills-
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settings
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Principles
Resource
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M
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Manipulative
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28
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and in parallel to the conventional undergraduate curriculum. This high level of integration should occur
both vertically and horizontally. The subject naturally lends itself to an overview and introduction in the
early years, to an evidence based approach to efficacy in the middle years, concluding with the CAM /
conventional medicine interface in the final years. This is detailed in Figure (2). Options for integration
within the existing course consist of:

CAM as a vertical theme

CAM as part of CSPPD

CAM as part of Pharmacology and Therapeutics
It is important that the course should be visible and not simply hidden away within an existing vertical
theme, nevertheless CAM is probably not important enough to stand alone as a vertical theme. CAM does
lend itself to inclusion within Pharmacology and Therapeutics, but there are many other aspects of CAM
rather than purely “therapeutics” that need to be explored. The best answer may be for CAM to become one
of the vertical themes that are incorporated within CSPPD.
Figure 2 Integration
Year 1
Why patients seek CAM
Years 3&4
Specific therapies
Evidence basis
Year 5
Holistic care
Integrated health
29
Educational Strategies
As well as a high level of integration, the course will clearly often be taught in a community setting. Within
this setting there may be many opportunities for multi-professional training and education (6).
Teaching Methods
Many different potential teaching methods have been identified, through an initial literature review, the
needs analysis and meetings with stakeholders. Clearly some large group lectures will be required, but even
from year 1 it would be hoped that CAM should be incorporated into the small group case-based learning. A
computer-assisted learning package on “CAM therapeutics” would be beneficial. Students would be
introduced, as core, to practical CAM within either their year 4 or 5 GP modules. A significant amount of
the course would be self-directed and students would submit critical appraisals and reflective essays to their
portfolio. There would be opportunities for innovative methods, for example, a lab-based homeopathy
practical taught by Biomedical Sciences.
Assessment
The course must be assessed and this assessment would require to be as highly integrated, as the course
would be. Assessment should occur within all years of the curriculum, both within-module and in end-ofyear exams. Assessment currently takes place within the Patient Study Report of the year 5 GP module:
“Patient study report - Should contain studies of 2 patients who utilise complementary therapies, followed
by a discussion. The study should focus on the overall management of the patient in the community rather
than the diagnostic process.”
Assessment should also take place within the portfolio, elective report and OSCEs.
A potential assessment map is detailed in Table 2. Again there could be opportunities within assessment for
novel approaches, such as an OSCE station on communication skills in which the student is faced with a
patient who has, for example, stopped their anti-hypertensive medication and started themselves on a herbal
therapy.
30
Table 2 Assessment Map
YEAR 1
YEAR 2
YEAR 3
YEAR 4
YEAR 5
Portfolio
Portfolio
Portfolio
Portfolio
Portfolio
Health and society ICP-Patient studies
Modular
Modular
Modular
assessment
assessments
assessments
assessments
OSCE
OSCE
GP-Patient
management
studies
Elective Report
Study Guide
The details of the course should be communicated through a study guide that would be similar to the CSPPD
study guide, and distributed in year 1. This would provide an overview of the course; including objectives,
content, teaching methods, assessment and resources. The study guide would also be available on-line at the
Edinburgh Electronic Medical Curriculum.
Learning Resources
Various learning resources require to be developed and available before the course is in place. Textbooks
and journal articles should be available within the medical library. The electronic curriculum could also
provide additional resources, such as links to other web sites or to text articles. A computer-assisted learning
package would be a vital resource, as would a list of local regulated CAM practitioners. Providing students
with “links” from the conventional curriculum to the CAM course at relevant points would be beneficial.
Educational Climate
31
The emphasis throughout this course should be based on self-directed, student-centred- enquiry. It is clearly
vital that the course should not present a philosophy of advocation, but one which centres around critical
enquiry, exploration of patient belief’s and wishes, and an ability to maintain an open mind to alternative
treatments, and alternative methods of healthcare.
Managing the Course
For the course to be successful and to achieve it’s objectives a “champion” must be found to manage the
course. They should be interested in CAM, but probably from a medical background. A CAM therapist
would not be an appropriate person to balance an evidence-based approach with a broad familiarisation, and
the concern here would be inappropriate advocation. Teachers need to be identified, and incentives must be
provided. There should be an overall curriculum committee that is responsible for implementing, managing
and evaluating the course. Effective evaluation will be essential and a realistic time-scale for the project is:
Needs analysis -Completed
Development of course-September 2002-July 2003
Implementation of course-October 2003
First evaluation June 2004
To help the change process to be successful it will be vital for the stakeholders to remain involved and for
momentum to be maintained (7). Through the needs analysis a broad ownership and a degree of consensus
with regard to the course has been generated, and this will do much to overcome the opposition to change.
Summary
This document outlines a proposal for an integrated undergraduate medical course in complementary and
alternative medicine. It is based on the findings of the needs analysis conducted on this topic in Edinburgh.
This project was funded by the Alexander Dykes Endowment Fund of the University of Edinburgh
References
32
1 Skilbeck, M. (1983). School-based curriculum development. In V. Lee & D. Zeldin, (eds.), Planning in
the curriculum. London: Hodder & Stoughton
2 Harden RM. Ten questions to ask when planning a course or curriculum. Medical Education 1986; 20:
356-365.
3 Harden RM. Approaches to curriculum planning. Medical Education 1986; 20: 458-66
4 Scottish Deans’ Medical Curriculum Group. The Scottish Doctor. 2000. URL: www.scottishdoctor.org
5 Edinburgh Electronic Medical Curriculum (EEMec). URL: http://www.eemec.med.ed.ac.uk/
6 Harden RM, Sowden S, Dunn WR. Some educational strategies in curriculum development: the SPICES
model. Medical Education 1986; 18: 284-97
7 Menin SP, Kaufman A. The Change Process and Medical Education. Medical Teacher 1989; 11: 9-16
33
Module or
Theme
Pharmacology
&
Therapeutics
Health and
Society
Year 1
Year 2
Year 3
Homeopathy and Herbal Medicines including
use of oils
Year 4
Year 5
Herbal
Medicines adverse effects &
interactions with
conventional
medicines
Introduction to
CAM – ‘Why
patients seek
CAM therapies’
‘Introduction to
Hypnosis’
Ethics
Ethics &
Resource
Allocation
CAM integrated into Evidence based Medicine, Communication and Consultation
CSPPD
Introduction to
communication
& consultation
skills
Talking to
patients about
their medicines
in
‘Talking with
Families’
Literature
search
skills
including
CAM
Communication
in specialist
settings
Principles of
study design &
critical appraisal
skills
Communication
Skills &
therapeutic
choices
Communication
& relationships
with CAM
practitioners
Dealing with
‘Difficult
consultations
‘Taking a
Drug
History’
‘Health Needs
of Elderly’
Use of
manipulation
therapies in a
clinical scenario
Loco motor
Belief systems ie
Spiritual needs
Public Health
& Health
Promotion
CAM and
population
health aspects
CAM therapies
and homeopathy
in GP
General
Practice
34
Holistic care in
GP including
CAM
‘Use of
acupuncture in
chronic pain
management’
Anaesthetics
Use of CAM in
palliative care
Oncology
PBL
Student Select
Components
CAM aspects within a PBL
case
Including CAM aspects within case based learning
CAM options throughout 5 years
35