Back to Front PageVOLUME 6, NUMBER 4

To Teach or Not to Teach:

The Role of Alternative Medicine in Medical School Curricula

By Barbara A. Gabriel

Patricia A. Muehsam, M.D., a lecturer in the Department of Medical Education at Mount Sinai School of Medicine, encourages students to perceive conventional medicine as a product of Western culture and to be open to multiple cultural perspectives on healing.

The overwhelming increase in recent years of health care consumer visits to alternative medicine practitioners has forced the question: Should complementary and alternative medicine (CAM) be included in conventional medical school curricula? America's 125 medical schools are responding with a small but growing number of courses that address healing methods historically dismissed as incompatible with the scientific rigors of Western medicine. But although many medical educators agree that CAM can no longer be absent from their curricula, there is heated debate over how CAM modalities should be presented to our nation's future physician work force.

In a November 1998 article in the Journal of the American Medical Association, David M. Eisenberg, M.D., Harvard Medical School associate professor of medicine at Beth Israel Deaconess Medical Center, and his colleagues found a 47.3 percent increase in visits to alternative medicine practitioners between 1990 and 1997, when visits topped 629 million, exceeding the total number of visits to all U.S. primary care physicians. They also found that expenditures for alternative medicine professional services increased 45.2 percent during the same seven-year period, conservatively estimated at a staggering $21.2 billion in 1997.

Another 1998 JAMA article by Miriam S. Wetzel, Ph.D., and her Harvard Medical School colleagues Dr. Eisenberg and Ted J. Kaptchuk, O.M.D., surveyed the number and nature of courses with CAM content in U.S. medical schools. Replies from 117 of the nation's 125 medical schools revealed that 75 offered elective courses in CAM or included CAM topics in required courses. Of the 123 courses including CAM content reported, 84 were stand-alone electives, 38 were part of a required course, and one was part of an elective. However marginalized, CAM is clearly beginning to permeate the curricula from which it has been historically excluded.

A Skeptical Approach

Thomas Wheeler, Ph.D., associate professor of biochemistry and molecular biology at the University of Louisville School of Medicine, was one of the first medical educators to offer a course dedicated to CAM. Titled "A Scientific Look at Alternative Medicine," Dr. Wheeler's elective course appeared in the University of Louisville's curriculum in 1992. "When I first started, I wondered if I had enough material to teach the course," he recalls. "Within a few years, I had so much material it was a question of what to leave out." Dr. Wheeler feels education about CAM modalities should be a required element of a medical school education: "There's no question that doctors should be aware of the evidence for and against different alternative approaches because their patients are using them and they impact health care."

But Dr. Wheeler's skeptical approach toward his subject matter sets him apart from many of his colleagues. He emphasizes that rather than teaching alternative medicine, he teaches about it. "Where I part company with most approaches to teaching CAM is that the majority of people who teach similar courses tend to promote alternative therapies," he explains. "My position is that such therapies should be held to the same standards of safety and efficacy as conventional medicine. The elements of conventional medicine taught in medical school are evidence-based and consistent with scientific knowledge about the workings of the human body."

Dr. Wheeler maintains that the same cannot be said about the majority of alternative therapies. "Many or most elements of alternative medicine are not well supported by scientific evidence. Some are scientifically implausible and contradict what we know about how the body works. Rather than encouraging these healing modalities, we should encourage critical thinking about them." Thus students in Dr. Wheeler's course carefully examine scientific evidence evaluating the claims of proponents of alternative medicine. Critical reading is combined with presentations from guest speakers who practice CAM methods ranging from acupuncture to herbalism.

Medicine and Culture

Like Dr. Wheeler, Patricia A. Muehsam, M.D., lecturer in the Department of Medical Education at the Mount Sinai School of Medicine, strongly feels that alternative medicine should have a place in medical school curricula. She believes that the current marginalization of such courses will only serve to further polarize the Western health care community from a consumer public increasingly dissatisfied with the way conventional physicians practice medicine. But the agreement between Dr. Muehsam and Dr. Wheeler ends there.

Dr. Muehsam, who has delivered presentations on curriculum development in CAM at AAMC annual meetings and is the founder of the AAMC Group on Educational Affairs Special Interest Group in Alternative and Complementary Medicine Curriculum Development, teaches one didactic and two clinical courses in CAM at Mount Sinai. She explains that the elective "Integrative Approaches to Health Care: A Survey Course in Complementary and Alternative Medicine" is "an attempt to get students to think outside of the culture of Western medicine."

"I try to get them to see that any health care system is a function of the culture that it is indigenous to," explains Dr. Muehsam. "There's a vast measure of approaches we cannot accommodate within our Western frame of thinking. Our worldview is one perspective among many of understanding disease and disease treatment, and it's necessarily limited by the biomolecular model." Dr. Muehsam explains that "Integrative Approaches," which she has taught since 1994, is half didactic and half experiential. "The experiential part is an attempt to get students to have a sensory experience that allows them to think beyond the limits of their individual perspectives." Students in Dr. Muehsam's class experience acupuncture, meditation, and Qigong as taught by experts in the fields.

But while she both teaches about and practices alternative methods, Dr. Muehsam maintains that she is not allied to any particular approach to the treatment of disease. Although she uses the term for its utility, Dr. Muehsam explains that "alternative" is not the terminology she prefers in reference to non-Western healing methods. Rather than advocating "alternative" methods over others, Dr. Muehsam explains that her survey course "is an attempt to teach students that physicians should be open to the use of multiple types of healing techniques, regardless of their origin."

"That's why I use the term 'integrative' in the course title," says Dr. Muehsam. " 'Alternative' has a somewhat negative connotation, implying that it's used instead of something else, that it's perhaps secondary - something one thinks about after he or she has tried Western medicine."

Dr. Muehsam also teaches "Clinical Experiences in Oriental Medicine," in which students shadow Oriental medicine practitioners in the community, and "Integrative Approaches to Health in Clinical Practice," in which students work with her in her own practice. Dr. Muehsam says that student attitudes have changed since she began teaching her survey course seven years ago. "I'm increasingly surprised at how open students are and how their questions beget the points I'm trying to make. I think there's a new breed of students. I don't know what's going to happen to them when they reach their clinical education because we haven't created an integrative medical education system where these ideas are woven into the fabric of medical education."

Dr. Andrew Weil welcomes the fourth class of fellows to the University of Arizona's Program in Integrative Medicine. After completion of the two-year fellowship, graduates are expected to establish similar programs.

Building Bridges With Integrative Medicine

Andrew Weil, M.D., clinical professor of medicine at the University of Arizona College of Medicine and founder and director of its Program in Integrative Medicine, seeks to build bridges between alternative healing modalities and the Western medical tradition. Like Dr. Muehsam, Dr. Weil perceives a "growing gap" between what consumers expect of health care professionals and the realities of medical education. Noting that half of health care consumers now seek the services of "alternative providers," Dr. Weil, who addressed the AAMC Council of Deans at its annual conference in 2000, foresees an even larger consumer movement away from conventional medicine unless health care providers are trained to provide patients with information about nontraditional therapies.

"I think that if the majority of people who seek alternative therapies had their first choice, they would go to M.D.s who embrace an integrative approach to medicine," says Dr. Weil. "They wouldn't have to necessarily be experts in, say, Chinese medicine, but they would know how to make referrals when appropriate." Dr. Weil also prefers the term "integrative" to "alternative" to describe the concept of medical care that he teaches at the University of Arizona. " 'Integrative' refers to a comprehensive model of medicine that is patient-centered, that emphasizes the centrality of the doctor-patient relationship, and that incorporates all healing methods for which there is reasonable evidence, whether they're from the conventional or alternative side," explains Dr. Weil. "Integrative medicine has much larger goals than just looking at CAM modalities."

Dr. Weil perceives integrative medicine as having the potential to restore the reasons why most people go into medicine - to foster healing and form productive therapeutic relationships with patients. "It's a significant movement, and I think it's urgent that medical schools begin incorporating it, not as electives, but as core courses in their curricula," he says.

Alternative medicine found its way into the curriculum of the University of Arizona College of Medicine in the mid-1970s, when Dr. Weil first began delivering two lectures as part of the required course "Social and Behavioral Sciences." Although those lectures remain the only required educational component in CAM at the medical college, Dr. Weil has since founded the Program in Integrative Medicine, in which primary care physicians are trained in integrative medicine through a two-year fellowship.

Taught to be future leaders in integrative medicine, the fellows are encouraged to set up similar programs in other institutions upon the completion of their fellowship. Dr. Weil's fellows are trained in CAM modalities ranging from botanical medicine to acupuncture to Qigong. He stresses that training in the critical analysis of research findings on such methods also comprises an important part of the program.

A training facility called the Integrative Medicine Clinic at the University of Arizona Health Sciences Center allows fellows to develop skills in interviewing patients and building doctor- patient relationships - components that Dr. Weil perceives as integral to the practice of integrative medicine. Based on their interactions with patients, fellows develop integrative treatment plans in concert with a panel of health care practitioners who represent a comprehensive cross-section of conventional and alternative specialties from pharmacology to Chinese medicine. Treatment plans are then implemented and outcomes monitored. Dr. Weil says the program is in the process of performing a comprehensive measure of patient outcomes. Patient demand is high - the clinic currently has a waiting list of 1,500 individuals.

To his critics who say alternative medicine providers cater mainly to the "worried well," Dr. Weil responds, "I wish they could come and see our clinic. We tend to get people with enormously complex medical problems that have defied the best efforts of standard medicine. Many people come to us as their last hope, and they're difficult challenges, but I still think there's a lot we can do for them."

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19 July 2001