Teaching complementary and alternative medicine in undergraduate medical education: a scoping review

Objectives This scoping review explores the extent to which undergraduate medical education have incorporated complementary and alternative medicine in their curricula and evaluates the teaching, delivery and assessment approaches used. Methods ERIC, Ovid Medline and Pubmed databases were searched with keywords related to “complementary and alternative medicine” and “undergraduate medical education” for relevant articles published until August 2020. Data extraction included the presence/absence of complementary and alternative medicine integration, program duration, instructor background, and assessment methods. Results Of 1146 citations, 26 met the inclusion criteria. Complementary and alternative medicine teaching in undergraduate medical education was widely inconsistent and not well aligned with clearly identified aims and objectives. Various complementary and alternative medicine disciplines were taught, demonstrated or observed, and several programs included teaching on evidence-based medicine. Educational outcomes mainly assessed student satisfaction and learning through self-evaluation and rarely assessed for effectiveness with regards to changing clinical practice or impacts on patient outcomes. Conclusions Inconsistencies in complementary and alternative medicine teaching and assessment in undergraduate medical education reflect the lack of defined graduate competencies. An evidence-based medicine component of an educational program is a potential solution to overcoming breadth and content challenges. Curriculum developers would be better guided with research that determines if complementary and alternative medicine program design, content and assessment influence clinical practice and/or patient outcomes.


Introduction
Medical educators encounter various challenges incorporating complementary and alternative medicine (CAM) teaching into undergraduate medical education (UGME). The term CAM relates to the use of non-mainstream practices, either together with conventional medicine (complementary), or in place of it (alternative). 1 Common complementary health approaches include the broad descriptors of natural products (herbs, vitamins, minerals, probiotics), and mind and body practices (yoga, chiropractic, osteopathic manipulation, meditation, acupuncture, breathing exercises). In addition to the enormous breadth of CAM, there exists a degree of uncertainty around the validity and efficacy of many widely used therapies. 2 Whereas conventional western medicine defines 'best practice' based on empirical trials utilising large patient populations, many CAM therapies boast an individualised approach where the practitionerpatient interaction is therapeutic rather than the therapy itself. 2 This poses a considerable challenge for educators tasked with determining the necessary acquisition of CAM knowledge and skills in UGME.
Despite a need to upskill medical students in CAM-related knowledge and practice, there has not been an authoritative consensus regarding the acquisition of CAM skills and knowledge in medical students at graduation or the optimal method to provide this education. This raises the question as to what evidence and scholarship can curriculum developers draw upon to plan and implement CAM curricula for UGME students? A preliminary search of the literature, whilst failing to identify any reviews which have systematically investigated CAM teaching in UGME curricula, did provide some insight into the challenges (and innovations) medical schools face in teaching and assessing student learning related to CAM practices. Stratton and Colleagues (2007) surveyed CAM educational programs funded by the National Center for Complementary and Alternative Medicine (NCCAM). They found an array of curricula exist to provide health professions students with the necessary knowledge, attitudes, and skills to address CAM-related issues, and the approaches to evaluating curricular efforts were equally diverse; limiting the survey to only those that received NCCAM funding means it is difficult to generalise the findings. 3 The second attempted to systematically evaluate evidence of effective CAM educational interventions for both biomedical doctors and medical students. 4 This review only focused on descriptions of randomized controlled trials (RCTs), nonrandomized controlled trials (non-RCTs), and before and after studies. Importantly, it did not specifically examine descriptions of integrating CAM materials in the broader context of UGME curricula, nor did it explore the variety of teaching, learning and assessment approaches UGME programs utilise. This latter issue is of particular interest as it is important to determine if there is a correlation between changes in student's CAM-related attitudes, knowledge, skills and the provision of patient care.
We, therefore, conducted this scoping review of primary studies to evaluate the different approaches UGME programs have taken to incorporate CAM teaching into their curricula and identify directions for future research. The specific research questions we sought to answer were: 1. do UGME programs teach students about CAM and, if so, which CAM disciplines do UGME programs teach students? 2. what teaching and learning approaches do UGME use to teach students about CAM? and; 3. how are UGME students assessed about their knowledge of CAM? In addition to these questions, this review also evaluated the effectiveness of CAM teaching in the included studies, using the Kirkpatrick Hierarchy for Assessing Educational Outcomes. [5][6][7]

Methods
This study adopted the "Preferred Reporting Items for Systematic reviews and Meta-Analysis extension for Scoping Reviews" (PRISMA-ScR) reporting protocol. 8

Search Strategy
Electronic databases ERIC, Ovid Medline and PubMed were searched for full-text articles describing the delivery of CAM teaching in UGME (see Table 1). Additional papers were found through a hand search of the reference lists of articles identified through the online database search.

Inclusion and Exclusion Criteria
There was no limit on the publication date. Only full-text articles written in English were included. Articles were limited to those that looked exclusively at UGME, with medical students only. Articles exploring medical students' or faculty members' attitudes regarding CAM were excluded. Articles that did not clearly describe the characteristics of CAM teaching within the UGME curricula (for example, topics taught in CAM programs, duration or frequency of teaching programs, methods used to assess student learning, etc.) were also excluded, as were general articles about CAM in medical education, and proposals for CAM curricula without implementation and opportunity for subsequent evaluation.

Key terms and Boolean Operators
Complementary and alternative medicine, CAM, complementary medicine or alternative medicine, homeopath*, Chinese medicine, undergraduate medical, medical school, medical education, medical course, medical cirricul*, teach, university.

Data Extraction and Charting
Data extraction was performed using a predetermined list, and included: • assesses learners' satisfaction with, or reaction to, the Intervention; the second level assesses modification of students' attitudes and perceptions and/or the knowledge and skills learned; the third level assesses changes in health professionals' behaviour or an institution's practice, and; at the top of the hierarchy, changes in patient health care outcomes. In this review, Kirkpatrick's Hierarchy was used to assess educational interventions as they relate to specific CAM programs taught within UGME curricula.

Synthesis of Results
Each of the included studies was described by the author, year of publication, and the characteristics listed above. Thematic analysis was conducted to identify commonalities between the included studies. No inferences were made about CAM teaching, learning, and assessment approaches if they were not explicitly stated. Literature searching, title and abstract screening, full-text review and data extraction and charting were undertaken by the first author (MS). Where there was any uncertainty regarding the aforementioned, these articles were reviewed independently by the 2nd author (JB) and then discussed until consensus was reached between both authors. The 2nd author also independently reviewed the data extraction and charting results once this process was completed by the first author.

Results
The primary search, which was conducted between July-September 2020, yielded 1146 citations -960 citations from Pub-Med, 32 from Medline and 154 from ERIC. After the removal of duplicate citations and those not written in English, 1127 remained. Following a review of titles and abstracts, 113 fulltext articles remained, of which 26 met the inclusion criteria. See Figure 1 for the complete search and study selection strategy. A summary of the included studies is found in Table 2 and Table 3. Two main categories of literature were identified: 1. those reporting whether CAM was included in a medical school's UGME curricula, and; 2. those describing the teaching, learning and assessment approaches implemented in UGME.

Is CAM Being Taught in UGME?
Ten studies directly addressed the inclusion of CAM in UGME curricula (see Table 2). Seven studies 9-15 utilised written questionnaires or surveys to collect program information, whilst two 16 11 Chitindingu and Colleagues 16 survey of seven South African schools reported one school was teaching both Traditional Medicine (T.M.) and CAM, five were teaching either T.M. or CAM, and one was teaching neither. T.M. relates to therapeutic practices that incorporate plant, animal and mineralbased medicines, spiritual therapies, manual techniques and exercises, often practiced in developing countries. 19 Whilst TM is regarded as distinct from CAM, TM practices may be included within CAM. 20 Data on what elements of CAM are taught in UGME was inconsistently reported. In general, of studies that looked at whether CAM was taught in UGME, acupuncture was the most frequently taught modality 11,12,17,18 followed by homeopathy [10][11][12]17 and manipulation or chiropractic therapies. 10,12 In studies evaluating how implemented CAM programs are taught, the most commonly taught or demonstrated CAM disciplines were acupuncture 21-25 manipulation/chiropractic 24,26,27 and massage. [21][22][23] Less frequently taught therapies included biofeedback 21,26 nutrition 21,28 analysis of medicinal plants 24 homeopathy 26,27 hypnosis 26 and osteopathy. 27 Several of the identified programs taught about the evidence base of CAM alongside the risks and benefits or offered an opportunity for scientifically evaluating CAM efficacy. 21,24,27,[29][30][31][32]

How is CAM Taught in UGME?
Sixteen articles 21-30,32-37 described specific CAM teaching, learning, and assessment approaches in UGME curricula. A detailed breakdown of the different approaches used is described in Table 3. The structure of teaching modules varied greatly between programs. In a unique approach, Da Silva and Colleagues 22 reported a split teaching program, where students attended CAM classes in their third year, followed by clinical placements in their fifth year. Meanwhile, other programs included integrated CAM teaching across three 28 four 24, 34 five 30 and six years 25 of their UGME programs. Other programs adopted a block approach, where teaching was delivered over a period of weeks to months. 27-29, 31, 35, 36 Teaching time also varied greatly across institutions. Duration of time ranged from a relatively brief 5 hours 21 , to the longest of 90 hours. 25 Several of the programs with integrated teaching across several years did not report on the total teaching time, including Frenkel and Colleagues 34 and Perlman and Stagnaro. 24 The teaching modalities used in the delivery of CAM education varied widely. Only one program 24 used a solely didactic approach. Others used a didactic approach in conjunction with some form of interactive teachings such as tutorials 24,30 hands-on practice 23 discussion-based learning 31,35,36 workshop 34 case and team-based learning 28 or student-led presentations. 35 In a commonly utilised approach, several programs included a clinical placement in combination with formal lectures or tutorials. 22,[25][26][27][28]31 These placements varied in length from one day 26 to four-afternoon sessions of unspecified duration 22 to 30 hours. 25 Bailey and Colleagues 21 reported a unique approach involving a seminar followed by an Integrative Medicine fair where over 30 providers interacted with students through a series of student-selected workshops that introduced fields such as nutrition, massage, acupuncture, yoga and biofeedback. Similarly, the program described by Lehmann and Colleagues 35 offered a unique one-day excursion to the European Library for Homeopathy (Kothen, Germany). Telephone interview lasting approximately 30 minutes was conducted with most respondents.
Most schools reported that they include CAM in their curricula (13/16), usually as part of a required course. Lectures constitute the most frequent method of information delivery, predominantly during the preclinical years. Acupuncture (in 10 schools) and homeopathic medicine (in 9 schools) were the interventions most often included. Only 2 schools reported that they provide instruction on the actual practice of one or more complementary therapies.

Sampson 2001 13
Survey of 125 U.S. medical schools Questionnaire to learn of approaches to CAM in curricula.
Of the 56 schools that had some form of relevant course offering, only nine had invited critical lecturers on occasion; their courses were otherwise generally supportive of CAM. Two course directors claimed to present information "neutrally," but did not teach critical methods or invite critical lecturers. Only four courses either presented a critical orientation or offered critical arguments in a way that significantly investigated advocacy arguments.

Survey
All respondents indicated that their curricula included CAM elements. However, the quantity of CAM within curricula varied widely between medical schools, as did the methods by which CAM education was delivered. General Medical Council requirements were the strongest factor influencing the inclusion of CAM, although medical student preferences were also important. Respondents were generally satisfied with the extent of CAM provision within their curricula, while a wide range of views on the appropriateness of CAM in the medical curriculum were held by faculty members. Generally, the instructors delivering CAM programs were either faculty members of the medical school or clinicians 29,30,[34][35][36] external CAM practitioners only 26,31 or both. 21,24,25,27,32 Several programs also included visiting experts and scholars from other universities. 24,28 In some instances, faculty members were noted to have undergone advanced CAM training. 24,32 Several programs involved qualified community or student CAM providers and practitioners, including those with an element of clinical placement. 21,23,26,27,31 Post course student evaluations were infrequently used to assess student experiences and overall course satisfaction. 26,31 Objective assessment of knowledge and learning was not performed. Where knowledge assessment was completed, it often entailed subjective self-reporting using a Likert scale or other quantitative measure. 22,23,[27][28][29]36 Few programs used appropriately coded and thematically interpreted qualitative measures. 34,35 Several programs did not have formal evaluative or assessment processes in place 24,25,30,37 or removed the evaluative process following a period of time. 21

Assessment of Education and Learning Outcomes
This review assessed the educational and learning outcomes of the aforementioned studies using Kirkpatrick's Hierarchy ( Table 2). [5][6][7] There was a clear trend toward Level 1 outcomes, where student reaction and satisfaction were measured in all programs, bar one 34 using a post-course evaluation. Likewise, a majority of programs achieved Level 2 outcomes by considering the achievement of learning outcomes by students who completed self-evaluations. 21

Discussion
This scoping review of CAM education in UGME demonstrates the emerging interest in this area. In view of the rising use of CAM and the potential for CAM-conventional therapy interactions, there is an increasing need for physicians to become familiar with common CAM therapies. 38 As reported, past and current inclusion of CAM teaching, even within schools located in the same country, is inconsistent. In curricula that include CAM, teaching and learning vary widely, both in terms of content and delivery. It appears agreed statements on the expected skills and competencies of medical students at graduation related to CAM therapies are yet to emerge. In the absence of this consensus, it is difficult to identify clear aims and objectives of any CAM teaching program within a medical course. The following discussion amalgamates the key findings and addresses their implications, with the overall aim of aiding in the development of consistent and equitable medical education.

Program Format and Design
The duration of teaching is one of the greatest areas of inconsistency amongst the included programs. Whilst a number had integrated CAM teaching across one or several years of their curriculum, the design of others was relatively brief, with few -or unspecified -dedicated teaching hours. 21,32,37 Meanwhile, several 'integrated' programs regarded the practices of mindfulness and self-care for students as an element of their holistic CAM curriculum. 23,30 Other medical schools considered mentioning CAM in areas of relevance -such as drug interactions and clinical oncology -constituted sufficient CAM teaching. 14 This could lead to a potentially inflated and inaccurate measure of the duration of CAM teaching, particularly within these integrated approaches.
In analysing the approach to teaching, it is clear experiential learning is favoured compared to a solely didactic approach. Nearly all programs favoured delivery methods that would enhance student engagement. These included tutorials, workshops and case discussions, alongside clinical placements with CAM practitioners. Whilst well received by students, most immersive methods only achieved Kirkpatrick's Level 1 and/or 2 outcomes, without an assessment of translatability to clinical practice and impacts on patient outcomes, which would require Level 3 and 4 outcomes, respectively. Various programs included clinical placements with CAM practitioners, the longest being 30 hours. 25 However, in the absence of a student evaluation or objective assessment tool, the benefits of clinical placement cannot be commented on.
Various programs focussed on specific CAM disciplines, the most common of which was acupuncture. [21][22][23][24][25] This reflects the identified difficulties in establishing a discrete knowledge base, as CAM disciplines require constant updating as new evidence and novel therapies emerge and gain traction within the general population. 3 In what proved to be a popular approach 21,24,27,[29][30][31][32] analysis of the evidence base surrounding CAM is one of the more common methods of teaching. In equipping students with the skill set needed to critically appraise evidence, the plethora of CAM therapies need not be delved into individually. Rather, students can draw their own informed conclusions without the influence of potentially biased and unsubstantiated claims. Despite this, not all programs included teaching on evidence-based medicine (EBM), rather focusing on specific CAM disciplines. In designing a sustainable CAM program, curriculum developers should consider the need for constant review and critical appraisal as new evidence emerges. The EBM teaching model presents a potential solution to a rather overwhelming and resource intensive area of education, where learned knowledge and skills can be adapted for differing CAM modalities, and beyond. Likewise, the qualifications of CAM educators for such programs must be consistent and their repeated involvement sustainable. Whilst many programs utilised communitybased CAM practitioners 25,26,31,35 difficulties in repeatedly sourcing appropriately qualified instructors were identified. 21 Where faculty staff were involved in teaching, several programs were sustainable for longer. 21,22,30 Whilst both CAM practitioners and faculty staff could both introduce an element of bias, this could be overcome with clear learning outcomes and an evidence-based teaching approach. In view of sustainability, it may be more appropriate to deliver teaching through faculty staff, some of who receive further training in EBM. Curriculum developers should consider and account for the additional cost of incorporating CAM programs within UGME.

Appropriate assessment and educational outcomes
Few of the programs performed formalised pre and/or postcourse student assessment or evaluation as a measure of the change in knowledge. This reaffirmed findings from Stratton and Colleagues 3 which reported the same observation in the programs receiving CAM education grants from the NCCAM. Instead, general qualitative statements were regarded as a measure of overall student satisfaction and increased knowledge. 21,27,34 Student reactions and knowledge (Kirkpatrick's Level 1, 2a, 2b) were the most commonly achieved outcomes, with student knowledge measured subjectively through student questionnaires. 22,[27][28][29]31,32 Whilst Frenkel and Colleagues 34 was successful in determining the willingness of learners to apply new knowledge and skills (Kirkpatrick's' Level 3 outcome), it was the only study to do so. Course designers within medical schools must create educational programs that aim to directly impact patient care, rather than increasing knowledge without a foreseeable change to clinical practice. This is an undoubtedly challenging task, particularly since many widely taught CAM therapies have not yet been proven efficacious by scientific standards. For medical educators to educate appropriately, an evidence base for positive patient outcomes must first be established.

Limitations
Articles may have been omitted due to the adopted search strategy, inclusion criteria, and limit of English language articles only. Grey literature was not performed. Several programs were incompletely reported, potentially influencing the outcomes reported in this review. Many medical school faculty and Deans who were approached did not participate, leading to potential selection bias. Studies incorporating face-to-face interviewing may also be subject to observation bias. A small sample size, apparent in several studies, could also reduce the power and, therefore, reliability of results. Post-evaluations using subjective qualitative Likert-based assessment do not provide an objective measure of program success, particularly where students' results cannot be compared to pre-program standards. As only the first three levels of Kirkpatrick's Hierarchy were reached, the patient implications of CAM in UGME could not be determined. No studies reported on the change in patient outcomes or healthcare delivery (Kirkpatrick's Level 4). Longitudinal prospective studies would provide curriculum developers with insight to the real-world effects of CAM education, where patient outcomes can be correlated to teaching interventions. Several studies did not report outcomes of interest, such as teaching duration, disciplines and teaching staff. 22,27,28,31,32,37

Conclusions
The aim of this review was to evaluate the various approaches for teaching CAM in UGME. Despite various limitations, it is apparent CAM teaching is inconsistently incorporated into medical schools at a multi-national level. The diversity in approaches reflects the lack of defined graduate competencies as they relate to this specific area. With a breadth of CAM disciplines and an array of teaching and learning approaches, there is no single recommended education program that has been demonstrated to produce positive patient outcomes. Although the concept of an EBM course appeals as a potential solution to overcoming the enormous breadth and content developments in CAM, ultimately there is a deficiency of evidence to demonstrate the real-life healthcare impact. Curriculum developers would be better guided with further research, aligning health outcomes with teaching, assessment and evaluation of proposed CAM programs.