"COMPLEMENTARY AND ALTERNATIVE MEDICINE UNIT"
COMPLEMENTARY AND ALTERNATIVE MEDICINE UNIT Clinical Skills #1 September 27 - October 1, 2004 CAM Sequence Director Sara Warber, M.D. Michigan Integrative Medicine Phone: 734-998-7715 INTRODUCTION TO THE COURSE UNIT The goal of this course unit is to provide first year medical students with an introduction to Complementary and Alternative Medicine (CAM). Instruction will focus on tracing patterns of CAM use by patients, articulating key issues facing CAM researchers and practitioners, and presenting a classification system for CAM modalities. Information presented within the one-week unit will provide a foundation for establishing effective relationships with patients who use a diverse array of medical treatments. This unit will also provide students with a foundation for future learning about CAM in subsequent classes and clinical experiences. Specifically, the unit will target seven Intended Learning Outcomes (ILOs) related to student knowledge of CAM and one tied to skill development. The unit will also lay the groundwork for achieving attitudinal outcomes associated with long-term immersion in the four-year CAM curriculum. INTENDED LEARNING OUTCOMES (ILOs) KNOWLEDGE Understanding of … 1. Similarities and differences in the way that complementary, alternative, integrative, and holistic medicine are defined. 2. Categorizations used by the National Institutes of Health (NIH) - National Center for Complementary and Alternative Medicine (NCCAM) to classify CAM modalities: a. alternative medical systems; b. mind-body interventions; c. biologically-based therapies; d. manipulative and body-based methods; and e. energy therapies. 3. Limitations of existing CAM classification systems. 4. General patterns of CAM use among diverse patient constituencies. 5. Factors influencing patient use of complementary and alternative therapies. 6. Factors inhibiting patient disclosure of complementary and alternative therapy use to physicians. 7. Basic knowledge underlying CAM material introduced in later course sequences (years one through four), including: a. knowledge of the most common CAM frameworks and approaches to health; and b. knowledge of evidence related to the safety and efficacy of primary areas within CAM in the treatment of major disease entities SKILLS Ability to… 1. Access evidence related to CAM, including scientific, experiential, and media information. Specifically: a. searching and locating appropriate sources of information about CAM treatment options; and b. conducting preliminary analyses of evidence related to use of CAM treatment options. ATTITUDES Demonstration of… 1. A preliminary appreciation of diversity in health beliefs upon which subsequent CAM course sequences (years one through four) are built, including: a. Openness to paradigms and traditions outside of conventional medicine that influence the clinical decision-making process for both physicians and patients; b. Respect for the influence of personal, cultural, ethnic, and spiritual beliefs on each patient’s experience of health and illness as well as on their clinical decision-making processes; c. Respect for individual patients’ decisions to use complementary and alternative therapies, and/or other self-care strategies; and d. Respect for the role that CAM providers play in the delivery of health care to diverse patient constituencies. INTRODUCTION TO CAM UNIT Monday – September 27, 2004 Guiding Questions o What is Complementary and Alternative Medicine (CAM)? o Why do patients use CAM therapies? o How pervasive is the use of CAM? To Prepare Students will be expected to review the following materials prior to attending class: 1. Overview of CAM NCCAM, NIH. A new portrait of CAM use in the United States. Complementary and Alternative Medicine at the NIH. 2004;11(3):1-3. (full report available online at: http://nccam.nih.gov/news/camsurvey) Warber S. Introduction to alternative medicines. In: Between Heaven and Earth: An Introduction to Integrative Approaches to Health Care. Reston, VA: American Medical Student Assn; 1999:10-14. 2. Why patients use CAM Astin JA. Why patients use alternative medicine. In: Fontanarosa PB, ed. Alternative Medicine: An Objective Assessment. Chicago, Ill: American Medical Assn.; 2000:16-25 Eisenberg DM. Advising patients who seek alternative medical therapies. Annals of Internal Medicine. 1997;127(1):61-69. NOTE: The five general articles on CAM offer different pieces of information. It will be helpful to you if you read them in the following sequence. First, read the article by Warber for an overview of CAM and brief description of the major modalities. Read the article by Astin next. In this article, Astin presents evidence on the various reasons why patients are pursuing CAM. The 2004 article by NCCAM/NIH provides information of the prevalence of CAM use. The fourth article you should read is the 1997 article by Eisenberg. In this article, he discusses ways in which to advise patients on CAM. CAM Overview The use of CAM by patients is rapidly increasing in the United States. The field of CAM encompasses a wide variety of modalities and practices, and is provided by an array of different health professionals trained in one or several practices of CAM. The National Institute of Complementary and Alternative Medicine (NCCAM), division of the National Institute of Health (NIH) groups CAM into five major domains. I. Alternative medical systems Alternative medical systems involve complete systems of theory and practice that have evolved independent of and often prior to the conventional biomedical approach. Many are traditional systems of medicine that are practiced by individual cultures throughout the world. Included within this domain of CAM are a number of Asian approaches, such as traditional oriental medicine or aruyveda and western approaches, such as homeopathy, anthroposophic medicine and naturopathy. II. Mind-body Interventions Mind-body interventions encompass a variety of techniques designed to facilitate the mind's capacity to affect bodily function and symptoms, such as, meditation, hypnosis, dance, music, and art therapy, and prayer and spiritual healing. III. Biologically-Based Therapies This category of CAM includes natural and biologically-based practices, interventions, and products, many of which overlap with conventional medicine's use of dietary supplements. Included within this domain are herbal medicine and special dietary, orthomolecular, and individual biological therapies.. IV. Manipulative and Body-Based Methods This category includes methods that are based on manipulation and/or movement of the body, and/or tissues, such as chiropractic care, massage therapies and acupuncture/pressure. V. Energy Therapies Energy therapies focus on re-aligning the energy fields posited to originate from within the body (biofields) or other sources (electromagnetic fields) to promote healing. The practices include, for example, Therapeutic Touch, Reiki, as well as biomagnetics. CAM FIELD EXPERIENCE Monday – September 27, 2004 Tuesday – September 28, 2004 Wednesday – September 29, 2004 Field Visits Students will have the opportunity to observe and/or experience the clinical practice of a CAM modality. To Prepare Obtain field visit assignment, directions and readings pertinent to the CAM modality you will be observing during the field visit by logging onto the CourseTools (CTools) page found on the Medical School portal and going to the Clinical Foundations site. (See: https://ctools.umich.edu/portal). Prior to the field visit, complete the following Readiness Assignment: 1. Read articles assigned to you based upon the primary CAM modality you are scheduled to observe and/or experience on September 27, 28, or 29. Information in these articles will greatly enhance your understanding of the CAM practices you will be observing/experiencing and enable you to ask more informed questions of the provider. a. A list of the CAM providers and their primary modality of practice is listed in CTools, accessible through the Medical School portal. b. Articles from the reading list will be distributed by the Office of Medical Education, 3901 Taubman Library. 2. Review the discussion questions listed on the “What to Observe during the Field Visit” form. These questions will help you hone your observation skills. On the day of the field visit, remember to: Dress professionally Be on time Ask to speak to another provider in the clinic if you can’t find your contact person Stay for the assigned time period Be respectful when asking questions of providers Follow specific directives given to you before and at the time of the visit After the field visit, respond to the discussion questions (“What you Observed During the Field Visit”) and complete the “Reflections on the CAM Field Visit” form. Reflecting on your experience immediately after the visit through writing will allow you to capture salient thoughts and feelings and bring them back more easily during the discussion. By 6:00 p.m. on October 1st, submit your “What you Observed During the Field Visit” and “Reflections on the CAM Field Visit” forms using the link provided on the Clinical Foundations site in CTools, or you may go directly to https://soleus.msis.med.umich.edu/currevalstd/. Both documents will be added to your CAM longitudinal portfolio, a web space created to archive CAM materials during your enrollment in medical school. CAM RESEARCH EVIDENCE Tuesday – September 28, 2004 Class Session Students will read a case study vignette, conduct searches/research in response to a series of assigned questions, then share results with classmates using a presentation format. To Prepare Prior to Tuesday (September 28): 1. Check pages ___ to ___ of this syllabus to see your sub-group, room and vignette assignments. 2. Read the vignette assigned to your subgroup. 3. Within your sub-group (you and 1 or 2 of your classmates), determine who will take responsibility for which questions. 4. Conduct the searches and research necessary to answer the questions, and get together with your sub-group to formulate answers. 5. Discuss how you want to present what you’ve learned from these questions to your classmates. Important Notes: a. Presentations = 15 minutes in length. b. Presentations should reflect learning related to the ILOs for the course. c. Oral presentations only. Use of PowerPoint and/or audiovisual equipment will not be possible given time constraints. d. Find answers to the assignment questions using at least two sources, at least one of which involves a search of the medical literature. Use these assignment questions to guide the order of your presentation. e. Be prepared to work in small groups during class time. Each student in the group needs to contribute information for at least one of the assignment questions. f. Be careful that your presentation holds together well. Connect your responses to the assignment questions in a way that paints a complete picture. Reflect on thought questions when thinking of ways to pull the information together. g. Be creative. Design presentations that engage members of the class! h. Contact Pat Martin at the Taubman Medical Library if you require assistance with the search process (email@example.com). Tuesday, September 28: 1. The entire class will meet in West Lecture Hall from 1:00-1:40 for introductory comments. 2. From 1:45 to 3:00 you will work in your sub-group to finalize your presentation. Feel free to go to room 2802 Medical Science II between 2:00-3:00 if you need assistance/advice from a librarian or access to a computer with Internet capabilities. 3. From 3:00 to 5:00, each sub-group will present what they have found/learned to members of the larger group. Faculty will visit the presentations and, as needed, provide feedback. Assignment Questions Step #1: Students within each small group should divide up answering foreground and background questions using multiple databases, books, and web information. (Remember, you are gathering information you will need in order to advise your patient.) (Reminder: Use questions #1-7 to guide your presentation.) 1. Formulate and answer several background questions required for understanding the case (e.g., “What is moxibustion?”). 2. Use the PICO (Patient Intervention Comparison Outcome) format to generate and answer at least one foreground question related to the therapies in the vignettes. Databases that might be useful include: naturaldatabase.com – access thru Taubman website consumerlab.com – commercial website Embase – access thru OVID Cochrane Reviews – access thru OVID Medline – access thru Pub Med or OVID medlineplus.gov google.com – Google web search nccam.nih.gov – web P- Patient: define the patient population of interest clearly I- Intervention: define the therapy or diagnostic test clearly C- Comparison group: define which therapy (placebo or other treatment) or gold standard diagnostic test to compare the results against. O- Outcome of interest: define which outcomes you and the patient are most interested in (e.g., death rate, side effects, intermediate outcomes). In the case of a diagnostic question, the outcomes of interest are the properties of the test itself (e.g., sensitivity, likelihood ratio). Patient Intervention Comparison Outcome REMINDER: Background questions refer to those that are designed to improve our general knowledge about a subject. We ask these questions quite frequently, especially early in our careers (e.g., medical school and residency). They are extremely important questions; answering them allows us to then ask more sophisticated foreground questions. These latter questions are usually patient-specific, and focus on specific decisions that practitioners make. Step #2: Prepare answers to these remaining questions… 3. What types of evidence are available – case reports, case series, observational studies, basic science, clinical trials, meta-analysis, other? Refer to: Guyatt GH, Sackett DL, Cook DJ. Users' guides to the medical literature. II. How to use an article about therapy or prevention. B. What were the results and will they help me in caring for my patients? Journal of the American Medical Association. January 5 1994;271(1):59-63. 4. What does the research evidence tell you? 5. What are some potential side effects and complications identified in the literature? 6. What information can patients find relatively easily on the web? 7. To what extent was this a practical way to locate information? Could you do this for every question that you might have? Was there anything particularly frustrating about the search process? Vignettes Assigned to Groups 1. 43 year old man, works in car factory, on the line, was working last week, strained his low back reaching for a part off to the side. He has never had previous low back pain, but is very uncomfortable now on the right side in the lumbar region. He wonders if he should go to a chiropractor for spinal manipulation. 2. 27 year old women with history of mild depression and no other medical history or medication use. She has heard about St. John’s Wort but wants your opinion before trying it. She is also wanting to know the right dose. How would your recommendations change if she was on birth control pills? 3. 48 year old women with hot flashes about 10 times per day. The patient knows that hormone replacement therapy has associated risks so she would prefer to use black cohosh. She wonders if this will be effective and safe for her and what products to use. 4. 57 year old man who is 6 months out from 1st MI. He is taking lipitor and plavix and aspirin and a Beta-blocker, all evidence-based medications. He would like to also make some dietary changes and has heard about omega three fatty acids and fish oils. He wonders if he should add these to his diet. 5. 65 year old man with benign prostatic hypertrophy. He is otherwise in good health, believing in general that one should stay away from doctors. He has read about saw palmetto and wants your opinion on its benefits, particularly on starting his urine stream and nighttime urination. If you think it is helpful, he wants to know the dose and products to use. 6. 35 year old male who is a musician and teacher. He often becomes quite anxious before performances or when he has to teach. He has recently been diagnosed with hypertension. He wants to do everything possible to control his B.P. without medication first. You are wondering if mindfulness meditation or Transcendental Meditation might help him with both of his problems. 7. 42 year old female with cancer who is undergoing intensive chemotherapy. She is having great difficulty with nausea from the chemotherapy and has heard that acupuncture can control that. What are your recommendations? Are there safety concerns? 8. 23 year old female who is 8 months pregnant with her first child. You examine her with your attending and discover that the baby is breech. The attending suggests a version procedure but the patient has heard of moxibustion. The attending asks you to investigate moxibustion so you can discuss with patient at next visit. Thought Questions - What gaps do you notice in the research literature with regard to complementary and alternative medical treatments? Who might you include in decision-making about whether or not to use a particular treatment option – and why? CAM SMALL GROUP DISCUSSIONS Friday – October 1, 2004 Discussion Focus Students will have the opportunity to reflect and discuss similarities and differences among CAM practices and between CAM and conventional medicine. To Prepare Refer to CAM Field Experience materials: “What to Observe during the Field Visit” (Discussion Questions) “Reflections on the CAM Field Visit” Readiness Assignment 1. Students should review readings and notes from the CAM Field Experience visit as this will enrich the quality of the small group dialogue. (Note: It is particularly helpful to review the notes you wrote on the “What you Observed During the Field Visit” form.) 2. Be prepared to discuss both the field visit and the assigned readings for the week. 3. By 6:00 p.m. on October 1st, submit your “What you Observed During the Field Visit” and “Reflections on the CAM Field Visit” forms using the link provided on the Clinical Foundations site in CTools, or you may go directly to https://soleus.msis.med.umich.edu/currevalstd/. Both documents will be added to your CAM longitudinal portfolio, a web space created to archive CAM materials during your enrollment in medical school.