ORIGINAL ARTICLES

 

Preparing medical graduates to practise in a changing environment: complementary/alternative medicine in the medical undergraduate curriculum of the university of the West Indies

 

 

SR Maharaj

Department of Community Health and Psychiatry, The University of the West Indies, Kingston 7, Jamaica, West Indies

Correspondence

 

 

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Keywords: Complementary/Alternative Medicine (CAM) Undergraduate Curriculum, CAM teaching model, healthseeking behaviour

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The Faculty of Medical Sciences at the Mona Campus of the University of the West Indies has recognized the growing trend among the public to express more than a passing interest in "alternative" medical practices. This trend can be associated with a number of factors which have energized a coexisting system of Folk Medicine which was formerly regarded as posing little threat to conventional medicine as society became more enlightened and sophisticated.

However, the idea of providing basic healthcare to people everywhere in the face of resource constraint, created a "space for culturally acceptable practices" in instances where conventional services were not available or accessible.

The promotion of healthy lifestyles opened the door to the idea of "a natural approach to life and living": no chemicals (medicines), intercessionary prayers for a natural healing, organic foods etc. All of this at a time when technology was having great success in developing new diagnostic machines, techniques, tests and operative procedures - but at great costs to the patients in the midst of a global economic recession.

Patients had a choice between new, costly high technology medicine or alternatively, low technology high quality care characterized by natural healing interventions which gave them a say in their health attainment and healthcare treatment/maintenance.

There was a compromise position of course, the integration of the better elements of both approaches - based on sound scientific evidence - where the two complemented each other, the so-called complementary medicine group.

There were protagonists for each group individually and advocates for an integrated system which could accommodate the best aspects of these systems in the interest of the patient and a holistic approach to patient care. There was a lot of information in the public domain about the pros and cons of conventional, complementary and alternative medicine. How was the public to know what to make of this information when it appeared that the "experts" could not agree on a common treatment regimen for any single ill-health condition?

The patients turned to their doctors for answers; many of these patients had gleaned much information on particular topics (of personal interest in some cases) from many sources including the Internet. It was becoming obvious that the doctors - those, who were unable to keep up with the subject of Complementary and Alternative Medicine in addition to the required reading for their Continuing Medical Education credits - were unable to provide meaningful information and advice which their patients sought from them.

This situation, in concert with others which were influencing the doctor-patient dynamic, became an important impetus for the Faculty of Medical Sciences (Mona Campus) of the University of the West Indies (UWI) to once again review its undergraduate medical curriculum to ensure that its graduates were being well prepared to meet the challenges of practising medicine in a changing environment.

Healthcare Training and Healthcare Services: A Brief Historical Review

Prior to the establishment of the University of theWest Indies and the first Caribbean Medical School in 1948, all West Indians physicians were, of necessity, trained abroad (1). Health services were available privately or from government sponsored health facilities - neither of which were usually readily accessible, even if available. Locals still relied heavily on Folk Medicine - the medicine of the people - brought by their forebears from Africa, India, China and the Middle East in the main. This meant that they had to rely on alternative sources for healthcare when the need arose.

Health-seeking Behaviour

Illness is a subjective evaluation by an individual that "something is wrong" and this is usually associated with a reduced ability to carry out one's social role (2).

Health-seeking behaviour in the context of such "social disruption" meant that before seeking outside assistance, self-diagnosis and self-treatment were attempted. If unsuccessful, and symptoms persisted or worsened, the advice of relatives or friends was sought for a remedy. As a last resort the sick person engaged the services of a "medicine" person.

This sequence draws attention to a range of issues including the beliefs pertaining to illness within a particular sociocultural setting and explains the validation and legitimacy of the folk medicine among the indigenous people.

In contemporary times, there is a range of alternative medical practices which have survived the modernization of the healthcare sector; these alternatives are available through both the formal and informal healthcare systems and are being delivered by trained healthcare professionals and others with varying claims to competencies gained through formal and informal training - but not registered or licensed to practice as healers, or are able to present supporting evidence to substantiate the validity of the proffered therapies.

The question is, should medical schools in the region bear this sociocultural/economic fact in mind when training their doctors and be more inclusive on the issues of healthseeking behaviour in terms of a health team approach with skills and competencies across a wider range of treatment modalities to facilitate holistic care? Should we also be forging working relationships with Alternative Practitioners whose approach to therapy finds resonance with our own standards vis a vis evidence based medicine?

Alternative Medicine in the Medical Undergraduate Curriculum, Faculty of Medical Sciences, Mona

A seminar titled "The New Public Health Challenges for the 21^st Century", held at the Faculty of Medical Sciences, UWI, Mona, in 1997, included a presentation on, "Alternative Medicine, Old Ideas with New Interests" (3) which highlighted the following:

* the use of Complementary or Alternative Medicine had increased in developing countries during the last few years; these countries had enacted appropriate legislation to protect both the public and the practitioners

* there are growing numbers of research units in universities, journals and associations of practi tioners of Complementary Medicine.

Other Faculty members (4, 5) also commented on the increasing popularity of this emerging trend. They extolled the virtues of the quality time and compassion which characterized the interaction between provider and user of these alternative practices and felt that this was being lost in the conventional doctor-patient relationship.

Alternative practitioners were trading on the historical acceptance of "natural cures" by persons (practitioners) who gave credence to sociocultural mores and folkways, whereas conventional physicians, with their paternalistic approach excluded the patient from the context of his/her illness as well as its cure - were seen to be less compassionate/caring and more episodic than holistic in their approach to healing.

Within the Faculty of Medical Sciences (Mona), it was felt by some that the practice and outcome of Traditional medicine in the Caribbean society should be assessed by way of controlled treatment trials (such as is being done in some US Universities which have established departments for study of complementary medicine) and by encouraging further research.

The Faculty has encouraged discussion and debate on the subject by hosting and having its staff participate in seminars, conferences and other public fora. Here they share platforms with alternative practitioners, have listened to their points of view but have not been able to find sufficient evidence to embrace the methods as "legitimate scientific healing methods." Despite this, the Faculty has adopted a policy of including in its undergraduate curriculum some Complementary/Alternative Medicine issues as a means of sensitizing and stimulating its medical students to explore the subject through further reading or by access to conventional practitioners (who have integrated some Complementary/Alternative Medicine practices into their standard medical practice) to act as mentors during this stage of the students' academic development.

Current Undergraduate Curriculum Content at the UWI Mona Campus

There are two major Complementary/Alternative Medicine inputs into the undergraduate curriculum:

i) prior to the 2001 curriculum reform, the first year clinical students were introduced in 1996 to a Complementary Medicine Seminar which had as its aims to describe some theories and practices related to complementary medicine and attitudes towards it (6). The methods most often requested for demonstration purposes by students during this seminar were Acupuncture, Reflexology, Reiki and Tai Chi.

ii) It was felt that with the review ofthe curriculum (2001) and the widening base of discussion of the subject, there was a further opportunity to examine the possibilities for including other aspects of Complementary/ Alternative Medicine which were being recognized as being necessary for inclusion in medical schools undergraduate curricula in developed countries eg Canada) (7). In the United Kingdom and Europe, the attitude of medical educators was similar with regard to the need for integrating aspects of Complementary/ Alternative Medicine into the Primary Health Care clerkships (8).

Special Study Modules

The 2001 revised medical undergraduate curriculum created the opportunity for Selectives which usually focussed on areas related to the wider definition of health but were not usually included or had only limited time in the curriculum. These Selectives are only available to a limited number of students and, although there are two which relate to Alternative Medicine practices, i) assessing spiritual health and, ii) an introduction to alternative medicine practices, only a total of twenty-four out of a possible one hundred and sixty students can access these Selectives because of various constraints including time.

Students Responses to the Experience

As yet there has been no formal evaluation, however, responses to practical demonstrations and opinions expressed in essays written as part of the evaluation of Selectives have been positive and have suggested that more on the subject of Complementary/Alternative Medicine should be included in the curriculum.

The Way Forward

If it is accepted that the general public needs advice about Complementary/Alternative Medicine and that doctors should be able to carry out this function, then there is a case for medical schools to provide what is regarded as enough exposure to facilitate functional literacy on the subject.

Undoubtedly, the young graduate will have to do further reading on his/her own as is the norm for CME and, if for instance, a conventional practitioner wishes to add acupuncture or any other skill to his/her practice, then that training can be pursued later on.

Many forms of Complementary/Alternative practices, unless these practices are outlawed, will become a parallel system which patients will want to access. This is very likely given the experience elsewhere. It therefore challenges the authorities and training institutions to design an appropriate response to either a perceived threat or opportunity to conventional healthcare systems. If one foresees opportunity, in the interest of patient care, then by integrating different approaches into patient management, the Hippocratic sense of traditional medicine, meaning the application of the ancient art of medicine which involves the exploration of the mind/body relationship of the sick - the holistic approach to patient care, can be enhanced.

Complementary/Alternative Medicine (CAM) Education Content

Complementary/Alternative Medicine Education in Canadian Medical Schools recommends the following:

* Definitions of CAM

* Typologies of CAM

* Utilization of CAM

* Reasons for using CAM

* Evidence

* Implications for practice to include: Safety, Doctor-Patient Communication and Attitudes/Respect

* Integration of CAM and conventional medicine

* Strategies for enhancing receptivity and openmindedness on the part of students, ie bridging strate gies/paradigms.

This model came out of a workshop to Develop a National Vision for CAM in Undergraduate Medical Education held in Canada in 2003. This proposed content was guided by Students Learning Objectives which included 8 on Knowledge, 3 related to Skills and 2 on Attitudes.

 

REFERENCES

1. Moyne Report (1938-1939) Royal West Indian Commission - Under Lord Moyne - His Majesty's Stationary Office (HMSO) London.

2. Coe RM. The Sociology of Medicine, 1970 McGraw-Hill.

3. Desai P. Alternative Medicine: Old ideas with new interests? West Indian Med J 1998;47(Suppl. 4):34-6.

4. Fraser HS. Alternative medicine and conventional medicine - overview. West Indian Med J 1998;47:157-61.

5. Rodgers-Johnson PEB. Complementary/alternative and conventional medicine. West Indian Med J 1998;47:162-4.

6. Desai P. Complementary medicine seminar for medical undergraduates of the University of the West Indies, Mona. West Indian Med J 2002;51:164-6.

7. Verhoef M, Best A, Boon H. Role of complementary medicine in medical education. Annals RCPSC 2002;35:166-70.

8. Owen DK, Lewith G, Stephens CR. Can doctors respond to patients' increasing interest in complementary and alternative medicine? 2001; BMJ 322:154-7.

 

 

Correspondence:
Dr SR Maharaj
Department of Community Health and Psychiatry, The University of the West Indies
Kingston 7, Jamaica, West Indies
Fax: (876) 812-3234
e-mail: satnarine.maharaj@uwimona.edu.jm