Resident-Initiated Integrative Medicine Curriculum in an Allopathic Family Medicine Residency

Introduction

I ntegrative medicine seeks to facilitate the body's innate healing response by neither rejecting conventional medicine nor accepting alternative therapies uncritically, but by using effective interventions that are natural and less invasive whenever possible. ¹ Integrative medicine has become widespread and increasingly popular among patients in the United States, ^2,3 and a growing number of allopathic physicians, especially in primary care, want to learn more about integrative medicine philosophies and modalities. ^4,5

Recommended goals for integrative medicine curricula for U.S. medical students and residents do not include making learners into expert practitioners of integrative medicine. Instead, existing programs aim to help physicians understand different integrative medicine modalities and their advantages, disadvantages, safety, effectiveness, availability, and cost. Further training goals are to promote self-reflection and self-care, to learn to practice open-minded skepticism, and to apply evidence-based principles to integrative medicine modalities. ^{5 –9} Physicians with basic knowledge in integrative medicine can counsel interested patients regarding their options, determine whether a conventional or alternative therapy is a more effective and safer treatment option, and dissuade patients from undergoing an unsafe or ineffective modality. ^7,10 A significant proportion of every physician's patient population uses integrative medicine modalities, but most do not disclose this to their physicians. ^4,11 Successful patient–physician communication requires that the physician present a demeanor that is accepting, respectful, open-minded, and nonjudgmental toward his/her patients' use of integrative medicine. ^10,12

Family medicine is an ideal field in which patients can benefit from their provider's having more knowledge about integrative medicine. ^9,13,14 In allopathic family medicine residency programs that do not yet have an established integrative medicine curriculum, there is a need for innovative ways to incorporate integrative medicine into the training. This article describes a unique approach in which a group of family medicine residents who were passionate about integrative medicine took initiative, established, ran and evaluated a weekly integrative medicine curriculum.

Methods

Brown University's family medicine residency is an allopathic program with 39 residents (13 per year) and is the only family medicine residency in the state of Rhode Island. In 2006–2008, integrative medicine was not part of any regular curriculum and existed only in the form of sporadic noon conferences a few times a year or occasional evening meetings outside the residency, in which a group of interested residents shared meals and ideas about integrative medicine. In 2008, this group identified a feasible time for weekly seminars during the noon hour. A resident coordinator invited speakers and sent out announcements of the weekly topic via e-mail several days prior to each event to all 39 residents as well as to faculty who had expressed interest in participating. Resident and faculty participation was voluntary. To choose topics, the group of interested residents held a first seminar and reviewed the choices throughout the whole academic year, tailoring the topics to the expressed interests and needs of the participants.

The seminars had several formats: (1) Invited guest speakers from the local integrative medicine community, with the goal of learning from local experts and getting to know local resources; (2) faculty speakers or resident speakers with interest and expertise in a particular integrative medicine modality, with the intent to activate integrative medicine resources within the residency program; and (3) group discussions about integrative medicine–related topics facilitated by a group leader involving every participant in active discussion to share everyone's personal views and experiences.

At the end of 1 year, participants evaluated the program using a modified nominal group technique. ¹⁵ This technique elicits positive and negative feedback from participants in an inclusive and nonjudgmental atmosphere in which each participant contributes equally to the feedback.

A faculty member who was not involved in the curriculum facilitated the modified nominal group evaluation process. The first step was to present the following evaluation questions to the participants to elicit feedback on our curriculum: (1) What were the strengths of the integrative medicine program? (2) How could it be improved? (3) How did you benefit from participating? Second, each group member silently wrote down his or her five personal responses to each question. Third, with the whole group, the items were pooled, clarified, and edited into themes, with the most popular items listed first. Then, from the pooled list, each participant ranked his or her top five items, awarding 5 points to the most important item, 4 points to the next, and so forth going down to 1. Finally, results were tallied, resulting in a rank-ordered, weighted list of the group's collective opinion. The program evaluation protocol was granted an exemption from formal review by Memorial Hospital of Rhode Island's human subjects committee.

Results

Thirty-seven (37) seminars were held from July 2008 to June 2009. Table 1 shows the seminar topics. The number of participants for each seminar averaged 6 residents (range 2–12) and 2 faculty members (range 0–8). Twenty-nine (29) residents and 16 faculty members participated in at least one integrative medicine seminar. Each participating resident attended an average of 8 seminars (range 1–33), and each faculty participant attended an average of 5 seminars (range 1–18). Ten (10) of the 39 residents in our program did not attend any seminars.

Nineteen (19) residents and 7 faculty members participated in the evaluation using the modified nominal group technique. Table 2 shows the results of the nominal group process, a weighted list of themes elicited from participants.

Discussion

In this study, family medicine residents with expressed interest in and passion for integrative medicine successfully initiated and ran weekly integrative medicine seminars for all residents and interested faculty. Student interest and initiative has driven integrative medicine curricular development in several medical schools, ¹⁶ and eight family medicine residencies in the United States include integrative medicine as a required component of the curriculum. ¹⁷ Most other family medicine residencies have no such existing training in integrative medicine. To our knowledge, a resident-initiated integrative medicine curriculum has not been described in the literature or evaluated to this point. This innovative approach served as a very practical and active method to improve education at our institution, and it may inspire residents in other programs to initiate such programs, should they desire more education in integrative medicine.

Our resident-led curriculum was created “on the run,” week-by-week and tailored to the interests of the participants, who rated this as an important strength. The content, which covered many of the main integrative medicine modalities (Table 1), was rated as the greatest strength of the program. Although the primary goal was familiarity with (not expertise in providing) integrative medicine, residents expressed a desire to gain practical skills. Many basic integrative medicine techniques such as the relaxation response, breathing techniques, or acupressure can be easily learned and incorporated in patient encounters. Participants clearly expressed the wish to have more focus on practical applications and hands-on practice with patients during the seminars, which we will try to implement in the next academic year. Another suggestion for improvement by our participants was to critically appraise the evidence for each presented modality, which also has been an important part of other integrative medicine programs. ^1,9,18,19

One of the most interesting and unanticipated findings of our study was that themes such as “supportive group,” “inspiring/enthusing/deepening experience,” “enjoying community,” and “getting to know colleagues more” were among the highest ranked answers among program strengths and personal benefits for participants. Residency is a time of great stress, and as many as 40%–76% of residents fulfill criteria for burnout. ²⁰ Integrative medicine programs at other institutions have used reflective journaling, mindfulness-based stress reduction, defining healing through the humanities (poetry/art), guided imagery, encouraging residents to define their own sense of spirituality, and other interventions to promote awareness about physician self-care. ^1,5,8 We included several of these “self-care” topics in our seminars (Table 1). The following individual quotes from the evaluation process suggest that our program was able to create a sense of connectedness and support, which may have served as an antidote to burnout for regular participants: “Reminded of my own values,” “Developed a sense of community within the residency,” “Thinking about self-care more often,” “Inspiring (keeps values and ideas alive during residency),” and “Something to look forward to.” To investigate this possible connection between integrative medicine seminars and improvement in resident's spirit further, future integrative medicine programs should include this observation in their evaluation process.

Integrative medicine programs like ours may help physicians-in-training to shift their focus toward salutogenesis, which is defined as the creation of health. ⁸ Currently, pathogenesis (disease-oriented care) is the focus of our medical education. Health-oriented care in a culture with epidemic rates of chronic diseases related to poor lifestyle choices and a core understanding of healing and prevention have many times been the subject of our discussions at the integrative medicine seminars. Integrative medicine programs may play a crucial role in balancing pathogenesis and salutogenesis in medical education. ⁸

Conclusions

Our conclusions are based on the experience of a single institution, and therefore may not be widely generalizable. Our residency is relatively large with 39 residents; smaller programs may find it more challenging to find enough interested and available participants to organize and run weekly seminars.

For family medicine residents with interest in integrative medicine, weekly seminars support their personal and professional growth and may improve their overall spirit while being in residency. For all family medicine residents, providing basic knowledge about integrative medicine enables them to have more informed discussions with patients interested in these modalities. Residents interested in integrative medicine can successfully organize their own education in integrative medicine during residency training with the support of community providers and interested faculty.