Medical student attitudes towards complementary and alternative medicine (CAM) in medical education: a critical review

Introduction

Patient use of complementary and alternative medicine (CAM) practitioners – a wide range of practitioners (e. g. acupuncturists, chiropractors, naturopaths and traditional medical system practitioners) and products (e. g. herbal medicines, nutritional supplements and homeopathy) which traditionally exist outside the conventional biomedical setting – has been exponentially increasing internationally over the previous decades [1, 2]. In some areas, CAM practitioner visits are now similar in numbers to visits and use of conventional medical approaches, and CAM practitioners’ numbers are similar to conventional physician numbers [3]. In addition to increasing levels of patient utilization, CAM is being increasingly integrated into healthcare systems and, in some countries (such as China), is already highly integrated into healthcare [4]. Philosophical divergence of conventional and CAM approaches to health has often resulted in significant professional tensions between CAM and biomedical practitioners, with significant and high-profile opposition to CAM use and integration in parts of the biomedical community [5–7].

Given findings that most people use CAM and conventional approaches concurrently [1], competition and resultant lack of collaboration between CAM and biomedical practitioners may be an incongruous situation that could ultimately be detrimental to patient/practitioner relationships. There is also general consensus that even if biomedical practitioners choose not to incorporate CAM practices, biomedical practitioners need to comprehensively understand other systems of healthcare that exist in their communities, basic information as to what these other health systems entail, and that they are very likely to encounter patients and practitioners who use them. As such, medical education accreditation bodies have endeavored to promote implementation of CAM content into medical curriculums to keep pace with community CAM activity and to bridge the gap between patients’ CAM and biomedical care [8, 9]. These efforts appear to have been productive, with US data indicating that in 2008, 90 % of US medical schools had CAM familiarization courses in their curriculum [10].

Stated reasons for the inclusion of CAM familiarization courses into medical curricula include the discussed exponential rise in CAM use amongst patients; poor, minimal or no medical student knowledge of CAM and confusion as to appropriate referral practices and subsequent poor CAM referral skills, medical student interest and curiosity in learning CAM (especially in the preclinical years of medical school) and to decrease possible communication deficits around their future mainstream medicine patient’s CAM use [8, 10–25]. However, the time allotted to CAM content in medical schools varies considerably. While medical education CAM content in Australia [8], Hong Kong [13] and the United Kingdom [12] appears to be minimal (with less than 5 h over an entire medical degree), in other countries such as Brazil [20] and South Korea [10], CAM content may be far more substantial and may even incorporate practical integration of CAM therapies [26].

However, despite the increasingly acknowledged need to develop CAM curriculum content in medical courses, and the apparent ad-hoc and variable manner in which this appears to be currently delivered, there has been little formal examination of this topic in the peer-reviewed literature of how different approaches to incorporation are perceived by medical students. The purpose of this paper is to remedy this gap and provide a guide for the medical education community by presenting the first critical review of the literature on major themes relating to medical students perceptions and attitudes towards CAM. Through systematic examination of this important issue, this paper provides the first review and synthesis of empirical research findings relating to medical student perceptions of CAM education and highlights a number of gaps and challenges facing future research in this area.

Methods

A comprehensive search of the literature in MEDLINE, CINAHL, AMED and PSYCINFO databases was conducted to obtain the major peer-reviewed literature on attitudes and perceptions of medical students to CAM. All databases were searched from their inception to January 2015. Databases were searched using standard terms and subject headings for complementary medicine, alternative medicine and integrative medicine, as well as terms for specific CAM disciplines (e. g. Chinese medicine, naturopathy, homoeopathy, acupuncture and chiropractic) and terms for specific CAM products (e. g. herbal medicine, supplements and vitamins). Appropriate terms and subject headings for medical education and medical students were also included. The search was confined to articles that were published in English.

One author conducted the search and downloaded the files into bibliographic management software (Endnote). Two authors independently examined the title and abstract of each result to identify relevant studies for inclusion. Papers that reported empirical research findings on medical student attitudes and perceptions towards CAM were selected. Studies not specifically focusing on this issue were also included if they provided empirical data on medical student attitudes and perceptions towards CAM. Any disagreement between authors regarding inclusion/exclusion was resolved by discussion. In situations where the abstract did not provide sufficient information, the full article was retrieved and examined before a decision was made. Database searches were supplemented by hand searches and all reference lists of papers reviewed for further references.

The search identified 917 articles using these search criteria. Of these, 815 were excluded as ineligible and abstracts and full-texts of the remaining 102 were read to compile a critical review to present, synthesize and analyze existing literature [27] on medical students’ attitudes and perceptions of CAM and CAM education. Twenty-one articles met the selection criteria to be included in the final review. Figure 1 summarizes the search strategy employed in this review, while Table 1 summarizes search terms used. The results are examined in terms of three broad areas: perceptions, attitudes and knowledge of medical students around CAM and CAM training; factors influencing medical student attitudes and perceptions around CAM and perceived impact of CAM training on future medical practice.

Figure 1:

Flowchart of literature review process.

Results

The context and findings of the 21 papers were extracted, grouped and summarized using an integrative review approach [28]. Papers were examined in relation to three main variables: perceptions, attitudes, and knowledge pertaining to CAM, the factors that shaped attitudes and perceptions, and the perceived impact of CAM training on future medical practice.

Based on this examination, ten major themes emerged from the papers. These are (1) medical students are generally interested in learning more about CAM; (2) among students in healthcare, medical students are those who currently have the least knowledge of CAM; (3) there is heterogeneity in interest in different modalities of CAM; (4) religiosity of medical students affects their interest in learning about CAM; (5) communicating with future patients about CAM use is a major motivation for medical students to learn about CAM; (6) medical students perceive a current lack of ability to refer future patients to CAM practitioners due to lack of knowledge of CAM; (7) the holistic principles of CAM are attractive to medical students and act as a motivator for medical students to understand CAM; (8) the attitudes of medical students change dramatically after exposure to CAM; (9) interest in CAM among medical students declines after the preclinical years of medical school (i. e. once medical students enter clinical component of their course); (10) evidence base is viewed as an important prerequisite of presented information in CAM familiarization classes. These individual themes are linked to individual articles in Table 2. The variables are discussed in detail below.

Discussion

This article provides the first comprehensive exploration of medical student attitudes and perceptions to CAM. Findings from this article suggest that medical students are interested in learning CAM and often see it as important and highly relevant to their broader medical education and their future care of patients after graduation. Medical students appear to be aware that there is a growing public interest in, and public demand for, CAM, and as such, students perceive that they should reflect on this phenomenon from clinical, social and legal perspectives.

In contrast to the high level of interest of medical students to engage with CAM in their medical curricula, there appears to be little integration of CAM into medical curricula. As such, medical students appear to have lower levels of knowledge of CAM than other providers. This differential may be the result of many factors including faculty opposition budgetary and time constraints or lack of teaching staff with the appropriate expertise required to formulate appropriate and well-encompassed course materials. High-profile opposition to inclusion of CAM content in medical education settings [6], whilst not necessarily reflective of student or physician opinion, may make some medical schools hesitant to delve into what is perceived as a controversial area. However, to date, there has been no formal examination of medical curricula across regions or institutions to see if the medical CAM curricula appropriately reflect community use, whilst ensuring critical application.

The finding that medical student interest in CAM declines after the preclinical years of medical school is an unusual phenomenon that warrants further examination and suggests different educational interventions may be necessary at different stages of the medical curriculum. This could be the result of the professional tensions between CAM and biomedicine, which may become more overt once students begin clinical practice, but could also have other underlying reasons that warrant further examination. Previous studies suggest that positive clinical experience with CAM is one of the most predictive factors of physician support for CAM [36]. It is possible that medical students in their clinical years have not been in practice long enough to observe such positive experiences. It is equally possible that medical students in their clinical years are for the first time influenced by negative or ineffective use of CAM. The impact of the perceptions and attitudes of clinical peers, or prioritization of newly applied conventional techniques by medical students, may also affect CAM interest.

The effects of medical education itself, and the critical skills this infers, in particular warrant further examination. The medical education focused on didactic, evidence-based, logical and rational deductive reasoning may not be perceived as entirely congruent with the paradigm of CAM [37], and this could influence medical student opinion. Developing an understanding of the prism through which students critically appraise CAM at different stages of their medical education is essential to ensuring that CAM education is appropriate and relevant.

The effects of religiosity of medical students and the draw of spirituality with respect to medical student attitudes and perceptions towards learning CAM warrant further exploration. Spirituality and religiosity have been associated with increased CAM utilization among the general public [38], and this phenomenon among medical students may simply reflect similar social trends as is observed in the broader population. The impact of prayer, suggested in some surveys – including those of medical students – to be among the most popular CAM, may confound these results.

Being able to communicate with future patients about their CAM was a major motivation for medical students to learn about CAM and a factor for medical student support of further incorporation of CAM content in the medical curricula. This reflects research in this area which highlights deficiencies in CAM–conventional communication between physicians and patients and improvements in care that may result from improved communication [39]. It is clear the CAM community (both CAM users and CAM practitioners) and the medical profession need to understand each other and the best place to create this is to provide continual and adequate CAM training to medical students at university level. Some commentators highlighted, in regard to patient/practitioner relationships, they could even be held accountable as doctors for not recommending or informing a patient about a safer and equally efficacious CAM therapy and as such, lack of knowledge around CAM could be detrimental to clinical practice [7]. Also, as patients rarely inform their doctors of their CAM use [13], the increase in knowledge and skills gained from learning about CAM could well further enhance the patient/practitioner relationship and may change the attitudes of medical students towards the field of CAM.

Educational exposure to CAM in many forms and in many papers was shown to significantly affect medical student attitudes to CAM. This may be reflective of the fact that, outside direct CAM training, there may be limited accessible opportunities for medical students. Evidence of CAM interventions was seen as the most important inclusion in CAM familiarization courses, but biomedical journals may not cover clinically relevant aspects of CAM such as effectiveness and efficacy, focusing instead on issues of safety and risk [40]. Media (medical and lay) coverage of CAM may present results more negatively than they would for conventional medicine [41] meaning that students would need to venture further into the peer-reviewed literature for information, which may be beyond their scope of training or difficult to access. As such, the medical school environment may provide one of the few opportunities medical students will have to access CAM information that is critical, objective and trusted.

Conclusions

The rise of CAM as a social and clinical phenomenon necessitates consideration of further inclusion of these topics in the medical curriculum, if future physicians are to be able to fully discharge their role as primary care providers in an increasingly medically pluralistic world. However, there are important considerations for medical educators in relation to CAM inclusion in medical curriculums, which need to carefully balance evidence-based principles with the holistic paradigms that make CAM attractive to many patients and practitioners. Inclusion of CAM needs to be done in an objective and critical manner, which is relevant to the learner. However, despite CAM forming an increasingly significant part of the contemporary healthcare sector in many developed countries, there is little research on which to base a truly evidence-based approach to CAM inclusion in medical curriculums, and any inclusion appears to be done in an ad-hoc and sometimes informal manners. Further research of differing CAM inclusion approaches and their impact on learning and patient care outcomes is needed. Curriculum planners should consider the importance of evaluating the impact of CAM inclusion in medial curriculums to better inform medical education planning, policy and implementation.