Complementary and Alternative Medicine in the Undergraduate Medical Curriculum: A Survey of Korean Medical Schools

Introduction

T he demand for complementary and alternative medicine (CAM) is increasing worldwide. High-technology medicine is not always effective and is often accompanied by neglected self-care and high cost. Several studies have demonstrated the widespread use and marked growing consumer market related to CAM. ^{1 –3}

An early study demonstrated that over one third of the United States population had experienced CAM at least once and that these subjects had typically visited more CAM practitioners than primary care physicians. ⁴ According to a recent Japanese national survey, 44.6% of patients have used CAM products. ³

Korea has a unique medical license system for medical doctors, which grants licenses for Western medicine-trained doctors (WMDs) and Oriental medicine-trained doctors (OMDs; the equivalent in Korea are the traditional Korean medicine doctors, or TKMDs).

Despite the less favorable attitude toward and understanding of CAM by WMDs than OMDs in Korea, ⁵ recent surveys have shown that CAM is widely used in Korea, with its use ranging from 29% to 53% among various patient populations. ^6,7 CAM also accounts for a large share of healthcare costs, and approximately 29% of the out-of-pocket health care expenditure in Korea is for CAM therapies. ⁶

Responding to the increasing demand for CAM, medical education is incorporating CAM into the curricula of medical schools. Many physicians including those in Korea feel that they lack sufficient knowledge of the safety and efficacy of CAM, and wish to receive more education on CAM modalities. ^{8 –10} In addition, medical students want to learn more about CAM during their undergraduate studies. ¹¹ Such interest is reflected in the United States, where CAM education as a required course in medical schools increased from 75 of 117 surveyed schools (64%) in 1998 to 113 of 126 schools (90%) in 2008. ^12,13 In Canada, a study conducted in the late 1990s reported that, even then, 12 of the nation's medical schools (75%) incorporated CAM courses into the undergraduate medical curricula. ¹⁴ A more recent study reported that 40% of European medical schools provide CAM courses. ¹⁵ According to a survey of Japanese medical schools in 2001, 16 schools (20%) had introduced CAM into the curriculum. ¹⁶ In Korea, CAM education was first provided 20 years ago. Oriental medicine, which can be considered a component of CAM, was formally incorporated into the conventional Western medicine curriculum in 1992.

Currently, the Korean Institute of Medical Education and Evaluation recommends inclusion of CAM courses in basic medical education. However, CAM education for medical students in Korea is uneven and not well integrated into mainstream health education. In addition, conflict between WMDs and OMDs or TKMDs in Korea is a social issue. Most OMDs receive training mainly in acupuncture, herbal medicine, and moxibustion. OMDs may feel that if medical school students acknowledge the various complementary modalities, including some practices that OMDs perform, boundaries between specialties would be less clearly defined.

In addition, there are several problems with the current CAM education of Korean undergraduate medical students. First, CAM is not taught based on evidence of efficacy or safety, but mainly on individual experiments or with a commercial purpose. Second, no legal system exists for CAM in Korea. In contrast, legal regulations for CAM exist in Germany, the United Kingdom, and the United States. ^17,18 Lack of legal regulations has resulted in CAM not being easily incorporated into clinical practice.

No reports have described the current status of CAM education in Korean medical schools, despite the strong need to standardize the educational curricula of Korean medical schools. The present study surveyed Korean medical schools of Western medicine to gauge the incorporation of CAM training into the undergraduate medical curricula and to obtain information about the organization and academic features of these courses.

Methods

Results

Replies were received from all 41 Korean medical schools surveyed. CAM was officially taught in 35 schools (85.4%), and 34 (97.1%) of these schools reported offering required courses. A total of 32 schools (91.4%) provided academic credit with an average of 1 credit per course (range, 0.5–2 credits). Table 1 shows the organizational aspects of the courses. The average amount of time scheduled for a CAM course was 13 hours (range, 1–36 hours), and three medical schools offered more than 30 hours of CAM courses.

Nine (9) of the 35 schools (25.7%) offered a single course. The CAM course was designated according to the four NCCAM-defined domains. Medical schools that provided a course that included introduction to CAM or integrative medicine were counted separately. Table 2 summarizes the categories of Korean medical school CAM courses. The most common topics were, in order of prevalence, introduction to CAM or integrative medicine (88.6%), traditional Korean medicine (57.1%), homeopathy and naturopathy (31.4%), and acupuncture (28.6%). Hypnotherapy (5.7%) and some practices of mind-body medicine (e.g., medication, yoga, relaxation, and qigong) were taught less often.

The predominant departmental affiliations of the CAM courses could not be defined. Even though the rehabilitation department mostly provided CAM courses, various other departments, including psychiatry, internal medicine, radiation oncology, and basic science provided CAM courses as well. Teaching formats consisted principally of lectures, practitioner lectures, and/or demonstrations. Although case studies or practices were used, there were only a few examples (4/35, 11.4%).

The directors of all 41 medical schools provided feedback regarding the core competencies that they felt were essential for medical students to be familiar with. Most course directors (40/41, 97.6%) considered open-minded attitudes about CAM, such as openness in discussing CAM with patients and in providing advice to patients about CAM modalities, the most important aspect of CAM education. Knowledge was the second most important aspect (32/41, 78.0%). The course directors emphasized specific knowledge of various CAM modalities and general influence on ethics, economics, and/or regulations of commonly used CAM methods. Few of the participating schools listed practical skills as a goal for learning about CAM (6/41, 14.6%).

Six (6) medical schools did not provide a CAM curriculum. The reasons for not including CAM in the curriculum included issues such as a non-evidence-based approach to assessing the efficacy of CAM, insufficient reliable reference resources, and insufficient time to evaluate the need for education about CAM.

Discussion

The present study is the first on CAM education in Korean medical schools. A total of 35 of the 41 schools (85.4%) featured CAM in the official curricula, and 32 of the schools provided academic credit for CAM courses. The most common course was introduction to CAM or integrative medicine. Staff lecture was the most frequently used educational format. Attitude was the most valuable core competency, and practitioner skill was the least valuable core competency.

Surveys of CAM courses in medical schools have been reported from the United States, Canada, and Japan. ^{12 –14,16} According to the 2008 Liaison Committee on Medical Education annual medical school questionnaire on U.S. medical schools, 113 of 126 schools (90%) offered CAM courses as required. ¹³ In contrast, a 2001 survey from Japanese medical schools demonstrated that only 20% of the schools offered CAM education. ¹⁶ The reason for the relatively low involvement rate of Japanese medical schools is not clear. The percentage of medical schools that taught CAM in Korea (85.4%) was similar to that of Canada (77%). Although there has been no previous official survey in Korea related to CAM courses offered to undergraduate medical students, CAM courses appear to be actively incorporated into Western medicine curricula with increasing popularity.

Most of the surveys concerning Western CAM curricula showed a tremendous heterogeneity and diversity in the content, format, and requirements among the CAM courses. As with U.S. medical schools, 91.4% of the Korean medical schools offered academic credit. ¹²

The course representatives who were in charge of CAM courses varied. Rehabilitative medicine was the predominant department offering CAM education, although several other departments including basic science offered CAM courses. In the United States, family or community medicine was the predominant department affiliation for CAM. ¹³ In Japan, anesthesia was the main affiliated department for CAM. ¹⁶

What should be taught is the issue of most relevance in standardizing CAM courses. In the United States, common topics have included chiropractic medicine, acupuncture, homeopathy, herbal therapies, and mind–body techniques. ¹² In the United Kingdom, topics have included acupuncture, hypnosis, homeopathy, and therapeutic massage. ²⁰ Acupuncture and homeopathic medicine were the most common courses in Canada. ¹⁴ In Japan, where Oriental medicine is more familiar than in other Western countries, Oriental medicine such as acupuncture and Kampo were common topics. ¹⁶ When all of the courses were categorized according to the NCCAM definition, traditional Korean medicine, homeopathy and naturopathy, topics related to natural products, and acupuncture were common topics offered in courses at Korean medical schools. These differences of common CAM-related topics among nations may be related to preferences toward particular CAM modalities of individual nations, regional characteristics, or cultural backgrounds.

Several teaching methods in addition to lectures are used. Multiple teaching methods were also reported in a study from the United States. ¹² No schools use practice interview sessions with patients for CAM. Reflecting the core competencies regarding attitudes such as open discussions with patients about the safety and efficacy of CAM, patient interviews as a teaching method would be a valuable option as an evaluation tool.

Initiating a CAM curriculum is a challenge. The introduction of any new content faces several barriers such as lack of an evidence-based approach, insufficiently reliable reference resources, and insufficient time to incorporate new courses. Similar barriers have been reported in the United States. ²¹ Faculty opposition, poor availability of a reliable educational source, and an already full curriculum added to the resistance. Lack of an evidence-based approach was the representative cause found in this study. These barriers and resistance might be overcome with an effort to provide an evidence-based CAM approach and active modulation to establish a CAM curriculum within the overall curriculum.

How many physicians openly discuss complementary medicine with their patients? Physicians often ignore questions from patients about complementary therapies for a variety of reasons. Lack of knowledge may be an important reason. The communication gap regarding CAM between patients and physicians is well known, and is reflected in the results regarding core competencies about CAM education reported here. Training students to talk to patients about CAM was the most common listed objective for the CAM education curriculum. It cannot be overemphasized that patients need guidance about what therapies are safe and effective, and this involves shared decision-making about CAM use. Here, evidence-based strategies for distinguishing among useful and useless interventions can be critical.

Knowledge was the second most important core competency reflected in the survey. Commonly used CAM modalities as well as legal, ethical, regulatory, and economic influences on the practice of CAM were also addressed. Few of the participating schools listed as a goal the practical skill required as a CAM practitioner. These findings were consistent with a 2004 study about core competencies in integrative medicine for medical school curricula from the United States. ²² The authors reaffirmed humanistic values (i.e., a respect for potential healing approaches and recognition of unknown factors that influence healing) and demonstration of skill to communicate effectively about patients' uses of CAM as core competencies.

Even though the number of medical schools providing education related to CAM has grown rapidly in the United States, a standardized set of curriculum guidelines for CAM has been prepared only for residency-level education. Efforts by U.S. medical school deans and educators are beginning to prioritize the incorporation of specific CAM areas into the overall medical school curricula by way of grants and national support from the Consortium of Academic Health Centers for Integrative Medicine. The situation of Korean medical schools is very similar to that of other countries, except for the national support provided in the US, as stated above. Specific CAM education and evaluation strategies for medical students need to be developed and applied. Many initiatives such as preparing reliable teaching resources, qualifying competent faculty, overcoming resistance from Oriental medicine practitioners, and obtaining sufficient funding for CAM education needs must be conducted.

Conclusions

This study has demonstrated heterogeneity in the content and requirements among complementary medicine courses in Korean medical schools. Without adequate resources of educational materials and professionals, it is clear why Korean medical schools are in the early developmental stage of complementary medicine education. To incorporate complementary medicine appropriately into the curricula of medical schools, continued efforts toward the development of a more stratified educational approach are required.