Responding to Patients’ Questions about

Complementary, Alternative, and Integrative Medicine:

Linked Independent Exercise and Small Group Session

Instructor’s Guide and Materials

Shelley R. Adler, PhD

Professor, Family and Community Medicine

Director of Education, Osher Center for Integrative Medicine

University of California, San Francisco

Yvette Z. Coulter

Manager of Education Program, Osher Center for Integrative Medicine

University of California, San Francisco

Ginger Polich

Medical Student

University of California, San Francisco

Katherine M. Hyland, PhD

Professor, Department of Biochemistry and Biophysics

Institute of Human Genetics

June M. Chan, ScD

Associate Professor, Epidemiology & Biostatistics and Urology

Steven and Christine Burd-SafewayDistinguished Professor

University of California, San Francisco

Acknowledgments: This work was partially supported by awards from the National Institutes of Health (National Center for Complementary and Alternative Medicine R25 AT00500, K07 AT003131, K07 AT006063) and a 2010-12 Medical Education Research Fellowship through the UCSF Office of Medical Education.

Table of Contents

Objectives3

Rationale3

Summary Description and Requirements3

Background Information for Small Group Leaders3

Instructions for Student Write-up and Presentation5

Small Group Session Outline and Instructions7

Teaching Tip9

Student Write-up: Grading Guidelines10

References11

Appendix: Take-home Assignment for Students12

Objectives

This linked independent research and small group exercise is designed to help students to:

  1. Identify and evaluate the quality of a variety of complementary, alternative, and integrative medicine information resources, including databases, printed materials, and Internet-based options.
  2. Summarize and synthesize information from a variety of sources to answer patient questions about integrative medicine and complementary and alternative medicine.
  3. Apply information about CAM in a simulated discussion with a patient(role play) about different health beliefs and health care models
  4. Generate a strategy for situations in whichthey need to have discussions with patients regarding modalities or treatments for which there isinsufficientor no information.

Rationale

In January 2005, the Institute of Medicine of the National Academies recommended that “health professional schools incorporate sufficient information about CAM into the standard curriculum at all levels to enable licensed professionals to competently advise their patients about CAM”

Summary Description and Requirements

This linked independent research and small group exercise was created and first taught at the University of California, San Francisco in 2002 and has been updated annually (to reflect evolving research in integrative medicine). The exercise was designed to enrich both independent and interactive components of the required curriculum in integrative medicine. This portion of the curriculum is presented in the “Mechanisms, Methods and Malignancies” course of the second preclinical year. Together with a two-hour overview lecture on the history, prevalence, and use of complementary and alternative medicine, this content forms the foundation of UCSF’s UME instruction in integrative medicine, and reinforces the social/behavioral sciences and epidemiology/evidence-based medicine curricular themes.

Format

(a) Independent, take-home, written research exercise (1-2 hours) that precedes

(b) Small group session (2 hours) with a facilitator and a group of 6-18 students

Intended Learner Audience

1st- and 2nd-year medical students

Instructor Requirements

This exercise is designed to be self contained, as well as freestanding; no prior experience with integrative medicine (beyond information contained in this guide) is required of the instructor. We have successfully delivered this exercise with clinical faculty, social and behavioral science faculty, social science graduate students, and fourth-year medical students.

Background Information for Small Group Leaders

Definitions

The NIH National Center for Complementary and Alternative Medicine defines complementary and alternative medicine (CAM) as a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine. Conventional medicine (also called Western or allopathic medicine) is medicine as practiced by holders of MD and DO (Doctor of Osteopathic Medicine) degrees and by allied health professionals, such as physical therapists, psychologists, and registered nurses. The boundaries between CAM and conventional medicine are not absolute, and specific CAM practices may, over time, become widely accepted.

Complementary medicine refers to use of CAM together with conventional medicine, such as using acupuncture in addition to usual care to help lessen pain. Most use of CAM by Americans is complementary. Alternative medicine refers to use of CAM in place of conventional medicine. Integrative medicine(IM) refers to a practice that combines both conventional and CAM treatments for which there is evidence of safety and effectiveness.

CAM is often grouped into broad categories, such as natural products (e.g., herbal medicines, probiotics, fish oil), mind-body medicine (e.g., meditation, yoga, tai chi), and manipulative and body-based practices e.g., massage therapy, chiropractic). Although these categories are not formally defined, they are useful for discussing CAM practices. Some CAM practices may fit into more than one category.

CAM Prevalence and Use

According to a nationwide government survey released in December 2008, approximately 38 percent of U.S. adults aged 18 years and over and approximately 12 percent of children use some form of CAM.(Barnes, et al. 2008). A 1997 phone survey of 1500 English-speaking US adults estimated that Americans spent $27 billion out-of-pocket for CAM services in 1997 (Eisenberg et al 1998). This figure increased to $40 billion in 2007.

Generally, people who use CAM are seeking ways to improve their health and well-being or to relieve symptoms associated with chronic, even terminal, illnesses or the side effects of conventional treatments for them. CAM is most often used to treat back pain or back problems, head or chest colds, neck pain or neck problems, joint pain or stiffness, and anxiety or depression. Although less prevalent, strong associations are still seen for individuals using CAM approaches to treat or provide symptom relief for cancer, cardiovascular diseases, and lung diseases (Barnes PM, et al. 2004).

CAM is attractive to many people because of afocus on treating “the whole person,”the promotion of good health and well-being, an emphasis on prevention, and the ideal of more personalized approach to patient concerns. Many types of CAM practitioners try to treat not only the physical and biochemical manifestations of illness, but also the nutritional, emotional, social, and spiritual context in which the illness arises. The overwhelming majority of patients using CAM approaches do so to complement conventional care rather than as an alternative to conventional care.

CAM use is more prevalent among women, among adults who have higher educational attainment or who engage in leisure-time physical activity and are not poor, as well as among adults who had one or more existing health conditions or who made frequent medical visits in the prior year (Nahin, et al. 2007). Dissatisfaction with conventional medicine is not an independent predictor of greater use (Astin 1998), however, delaying or not receiving conventional care because of cost is associated with CAM use (Barnes, et al. 2008).

Communicating with Patients about CAM

Of those patients who see both an MD and a CAM practitioner, the overwhelming majority seeks care from their physician before they see an alternative provider. Despite the growing numbers of patients seeking CAM, less than 40% of alternative therapies used are disclosed to physicians. In a 5-year multiethnic prospective cohort study of women with breast cancer, 54% of those who were being treated by an alternative practitioner disclosed their CAM use to their physicians, in contrast to 94% who discussed details of their biomedical treatments with their alternative practitioners (Adler and Fosket 1999).Discussions about CAM offer valuable opportunities to explore a patient’s health care beliefs and concerns. A lack of communication may be potentially dangerous, as some CAM therapies can interact adversely with conventional treatments.

Patients may be reluctant to disclosepersonal usage of CAM to their primary care physicians for a number of reasons. The most frequently cited reason for lack of disclosure in a study of CAM use among breast cancer patients was the belief that the physician was not interested in the patient’s use of CAM. Even when patients attempt to disclose CAM use, the physician is often unresponsive (Adler and Fosket 1999). Other reasons include the belief that their physician won’t have adequate training/knowledge or may be biased against alternative health systems. Some patients feel that their CAM use is not relevant to medical decision-making. This is borne out in a recent survey of patients who sought care from both a conventional and CAM practitioner. Sixty percent of these patients did not reveal their use of CAM to their physician and gave the following reasons for their non-disclosure: “It wasn’t important for the doctor to know” (61%), “The doctor never asked” (60%), “It was none of the doctor’s business” (31%), “The doctor wouldn’t understand” (20%), “The doctor would disapprove,” (14%) and “The doctor wouldn’t continue to care for me” (2%) (Eisenberg, et al. 2001).

Both patients and physicians agree that when CAM is discussed, the doctor-patient relationship is enhanced. CAM discussions between patients and physicians, however, are infrequent; and the CAM discussions that do take place are typically initiated by the patient (Adler and Fosket 1999; Roberts, et al. 2005a). Patients and physicians blame one another for the communication gap. The majority of oncologists, for example, attribute poor communication about CAM to patients’ unrealistic expectations, poor judgment, or denial; while the majority of patients attribute poor communication about CAM to physicians’ inflexibility toward CAM (Fitch, et al. 1999; Adler, Wrubel, Hughes, Beinfield 2009).

In summary, most CAM users seek care for chronic problems with bothalternative and conventional medicine because they perceive the combination to be superior to either alone, but many do not discuss CAM use with their primary care provider. The students will explore the issues that arise in introducing the topic of CAM use and in communicating with patients regarding IM/CAM use.

Instructions for Student Write-Up and Presentation

The following information should be provided to students at least two days before the scheduled small group session (see Appendix A: Take-home Assignment for Students).

Individually research the questions asked by the patient in your assigned clinical scenario, using at least four information resources (e.g., PubMed, printed materials, commercial websites). Where possible, include a randomized controlled trial or review article, as well as Web-based resources of both high and low quality. The NIH National Center for Complementary and Alternative Medicine lists ten factors to consider in evaluating Web-based CAM resources( You will have the opportunity to discuss the strengths and weaknesses of the various information sources in small group.

Prepare a one-page summary (to be handed in to your small group leader) that includes (1) a description and assessment of quality of each of the resources you used and (2) a paragraph summarizing the information you would discuss with the patient at a follow-up visit.

Be prepared to describe and explain to your small group how you would respond to the patient’s specific question(s).

Case 1

CG, is a 56-year-old man who was diagnosed with an anaplastic astrocytoma several months ago. His tumor was not surgically ressectable, but he is tolerating radiation and chemotherapy well. He comes in for a routine follow-up visit having read on the Internet that high doses of melatonin might be helpful for patients with brain tumors. He wonders if he should try melatonin and, if so, wants to know if it would it be safe to take along with his chemotherapy and anti-seizure medications (temozolomide, keppra, and lyrica). How would you advise him?

Small group facilitators: For more information on melatonin, including a summary of current research findings, see:

Case 2

MW, a 47-year-old man is diagnosed with low risk prostate cancer. Surgery is scheduled with radiation planned to follow. During pre-op consultation two weeks later, the patient raves about coenzyme Q10 (CoQ10), a supplement he has been taking since diagnosis. He explains that this enzyme is going to help him beat his cancer and prevent it from recurring. He then asks whether you think the specific brand he is using is the best on the market. How do you respond to this patient’s questions and use of CoQ10?

Small group facilitators: For more information on CoQ10, including a summary of current research findings, see: .

Case 3

SM, a 44-year-old woman recently diagnosed with ductal carcinoma in situ, comes in for her annual check-up, describing some “achy” localized low back pain that began 2 weeks ago. She got significant relief of similar pain 4 years ago when she was treated by a chiropractor, so she asks if you think spinal manipulation would help her again. How would you advise her?

Small group facilitators: For more information on chiropractic, including a summary of current research findings, see:

Small Group Session Outline and Instructions

Activity and Timing / Discussion Questions / Prompts for Further Discussion
Introductions
Describe structure of the session’s activities
(10 mins.)
Exercise A, Part 1
Form three sub-groups, based on the case each student researched:
Case 1 (Melatonin), Case 2 (CoQ10), or Case 3 (Chiropractic)
(20 mins.) / Which information sources were most useful (and why)?
Which sources were biased (and how)?
What advice or recommendations would you offer the patient in a follow-up appointment?
At the end of the discussion, students will select a member of their sub-group to summarize their findings for the larger group.
Exercise A, Part 2
Reconvene full group; a representative from each sub-group briefly describes the case and shares recommendations.
(30 mins.) / What was your reaction when first reading the case?
Did your thoughts/opinion change after completing some research?
Did your thoughts/opinion change after the discussions in subgroups?
Exercise B
Ask for two students to volunteer for a single role-play focusing on the CoQ10 case. One student from the CoQ10 group will serve as the doctor; a student from one of the other groups will serve as the patient; and the rest of the students will serve as the feedback group.
(30 mins.) / Students participate in one 5-minute role-play based on the patient recommendations formulated in Exercise A (i.e., What advice or recommendations would you offer the patient in a follow-up appointment?)
After the role-play, discuss the following:
From where do you think the patient might have obtained his information?
Why might the patient be so assured of the benefits of CoQ10?
The majority of the evidence base for CoQ10 and cancer pertains to breast cancer. Does this affect your advice to a prostate cancer patient? Why or why not?
As a physician, how would you respond to the concerns regarding CoQ10’s antioxidant properties versus radiation therapy’s oxidizing properties? Would this undocumented risk outweigh potential benefits?
How would you as a physician come to a decision regarding the quality of unregulated dietary supplements?
Discuss general guidelines that you might use in evaluating a non-biomedical cancer therapy (e.g., health risks, cost, potential for benefit).
Exercise C
Discuss IM/CAM therapies; encourage students to explore patients’ understandings of their illness and what they might be seeking by their CAM use
(15 mins.)
Ask students to think from the patient’s perspective and imagine some of the physical and emotional challenges associated with illness. Explain that students may share examples from personal experience with family and friends, if they feel comfortable.
Generate a list (orally or written on board). /
  • Fear, hopelessness, sadness, anger, guilt
  • Helplessness, lack of control
  • Anxiety, depression
  • Local and generalized pain
  • Weakness and fatigue
  • Nausea and vomiting
  • Loss of mobility

Focusing on the student-generated list, ask students to think about where conventional medical care may fall short or be perceived to fall short of meeting patient needs. /
  • Less attention paid to psychological and social distress (including disempowerment and lack of meaning
  • Less emphasis on overall quality of life
  • Isolation due to fragmented care

What types of complementary interventions could fill these gaps? /
  • Spirituality
  • Movement therapies (Yoga, Tai Qi)
  • Meditation
  • Massage/Manual therapies
  • Guided imagery
  • Traditional healing systems (Ayurveda, Chinese Medicine)

Encourage students to share the approaches they themselves take to stay well or feel better.
Draw attention to the similarities between informal student-provided approaches and IM/CAM.
Concluding Thoughts
(15 minutes)
Integrative medicine is not synonymous with complementary and alternative medicine. It has a larger meaning: it calls for restoration of the focus of medicine on health and healing and emphasizes the centrality of the patient-physician relationship. Given what we’ve just discussed about how some patients understand illness and why they use CAM, how can the principles of integrative medicine be used to address issue health issues? / *The principles of integrative medicine

*The principles of integrative medicine include:

  • A partnership between patient and practitioner in the healing process
  • Appropriate use of conventional and alternative methods to facilitate the body's innate healing response
  • Consideration of all factors that influence health, wellness, and disease, including mind, spirit, and community, as well as body
  • A philosophy that neither rejects conventional medicine nor accepts alternative therapies uncritically
  • Recognition that good medicine should be based in good science, be inquiry driven, and be open to new paradigms
  • Use of natural, effective, less-invasive interventions whenever possible
  • Use of the broader concepts of promotion of health and the prevention of illness as well as the treatment of disease
  • Training of practitioners to be models of health and healing, committed to the process of self-exploration and self-development

(Weil 2010)