Integrative medical education: educational strategies and preliminary evaluation of the Integrated Curriculum for Anthroposophic Medicine (ICURAM)

Histology education in an integrated, time-restricted medical curriculum: Academic outcomes and students' study adaptations

In an ever-changing medical curricular environment, time dedicated for anatomical education has been progressively reduced. This happened at the University of Michigan Medical School starting in 2016-2017 when preclinical medical education was condensed to one year. Histology instruction remained integrated in organ system courses but reduced to a lecture-only format without scheduling time for laboratory exercises, requiring students to study virtual histology slides on their own time. In accordance with the shortened instructional time, the number of histology examination questions was reduced more than twofold. This study analyzed students' histology examination results and assessed their motivation to learn histology and use of educational opportunities before and after these curricular changes were implemented. Students' motivation to learn histology and their evaluation of histology lectures increased in the new curriculum. However, students devoted less study time to studying histology. Students' cumulative histology examination scores were significantly lower in the new curriculum and the number of students with overall scores <75%, defined as a substandard performance, increased more than 15-fold. Academically weaker students' histology scores were disproportionately more affected. As medical educational strategies, priorities, and curricular frameworks continue to evolve, traditional didactic topics like histology will need to adapt to continue providing educational value to future health care providers.

Naturopathy, complementary and integrative medicine in medical education - position paper by the GMA Committee Integrative Medicine and Perspective Pluralism

Background

A large part of the population in Germany makes use of naturopathic, complementary and integrative medical treatments. There are now numerous scientific studies that provide evidence of efficacy for certain indications. At German medical faculties, selected procedures and their application are taught within the cross-sectoral unit called QB 12 and some elective courses, with a focus on specific aspects are offered. So far, however, there has been no structured curriculum that longitudinally anchors teaching across medical studies and enables all students to consider naturopathic and complementary medical options for patient care later on and to integrate them effectively into the diagnostic and treatment process.

Objective

The aim of this position paper is to show the relevance of this topic for medical education, to clarify terminology and to present core competencies and possible implementation options for training.

Method

The Integrative Medicine and Perspective Pluralism Committee of the German Association for Medical Education developed this position paper in a multi-stage consensual process, in cooperation with the Forum of University Work Groups on Naturopathic Treatment and Complementary Medicine.

Results

First, different umbrella terms were discussed and an existing definition of integrative medicine and health was chosen for subsequent use. Building on this step, the status of education and its scientific foundation in Germany was considered in an international context. In the next step, a competency profile for medical training, consisting of seven areas of competency, was developed and described in detail with regard to naturopathic, complementary and integrative medicine. Implementation options were identified using possible starting points in the curriculum and using established examples of best practice.

Conclusion

Despite different priorities at each faculty, it was possible to find an agreement on the development of competencies and anchoring them in medical education on the basis of a common definition of terms. Currently, the implementation in the mandatory and elective areas is very heterogeneous. As part of the current revision of the Medical Licensure Act, there are many possible starting points for the integration of naturopathic and complementary medical teaching content, especially in interprofessional and general practice courses. The implementation and accompanying research of targeted teaching settings should lay the foundations for a long-term and binding integration into medical education. Overall, it is clear that medical education in the field of naturopathy and complementary and integrative medicine has the potential to develop comprehensive core medical competencies.

Vermittlung des biopsychosozialen Modells in der universitären Lehre: Konzeption und Durchführung eines Seminars mit Betroffenen und Experten aus Dermatologie und Psychosomatik

Ziel der Studie Zahlreiche Studien zeigen, dass chronisch entzündliche Hauterkrankungen mit starken Einbußen in nahezu allen Dimensionen der gesundheitsbezogenen Lebensqualität einhergehen. Ziel war es daher, in der universitären dermatologischen Lehre ein extracurriculares Seminar anzubieten, um Medizinstudierenden bereits während ihrer Ausbildung praxisnah das erweiterte biopsychosoziale Modell zu vermitteln und sie frühzeitig für das psychosomatische Grundverständnis zu sensibilisieren.

Methodik Den Studierenden der Dermatologie (i. a. 7. Semester) wurde seit dem Wintersemester 2018/2019 ein zusätzliches Format auf freiwilliger Basis als einmaliges Seminar angeboten, durchgeführt und evaluiert. Insgesamt nahmen 25 Studierende teil, und 22 Fragebögen wurden anschließend deskriptiv und inhaltsanalytisch ausgewertet.

Ergebnisse Die Ergebnisse zeigen, dass großes Interesse und Offenheit für das psychosomatische Grundverständnis seitens der Studierenden besteht. Dabei wurde deutlich, dass die konkrete Option auf ein gemeinsames Zusammentreffen von interessierten Studierenden, Betroffenen und Fachärzten aus Dermatologie und Psychosomatik eine besondere Rolle einnimmt. Studierende nehmen die übliche Fokussierung auf das rein Biologische als unipolar und unvollständig in ihrer derzeitigen universitären Ausbildung wahr.

Schlussfolgerung Fächerübergreifende Seminare unter Anwesenheit von Betroffenen und im gemeinsamen fächerübergreifenden Diskurs tragen zur frühzeitigen Sensibilisierung auf das gleichzeitige Vorliegen von psychologischen und physiologischen Prozessen innerhalb ein und desselben Ereignisvorgangs bei. Die holistische Betrachtung scheint einen günstigen Einfluss für die eigene innere Haltung eines zukünftigen Arztes oder einer zukünftigen Ärztin zu haben.

Empathy, well-being and stressful experiences in the clinical learning environment

OBJECTIVE

This study examines whether students in the clinical phase show reduced well-being and lower empathy scores compared to preclinical students. Furthermore, it explores students' most stressful experiences.

METHODS

A cross-sectional mixed-methods study was conducted among medical students of the revised patient- and student-centred curriculum at Witten/Herdecke University (Germany). An online survey included questions regarding empathy (JSPE-S), well-being (WHO-5), distressing factors in the learning and clinical environments, mistreatment and thoughts of dropping out.

RESULTS

176 (34 %) of 517 medical students completed the questionnaire, 73 being preclinical and 103 clinical students. Despite lower well-being, clinical student did not demonstrate lower empathy levels. Main stressors during the clinical phase were negative physician role models and financially focussed care rather than challenging patient encounters. Compared to preclinical students, clinical students showed more mistreatment experiences and higher ratings towards thoughts of dropping out.

CONCLUSION

Our results illustrate contemporary challenges to establishing a learner-centred clinical environment that nurtures well-being and empathy of medical students. The sustainment of empathy despite more stressful experiences and lower well-being may be due to protective factors.

PRACTICE IMPLICATIONS

The paper suggests activities to support clinical students to find ways to adapt the clinical learning environment to students' needs.

Information and Training Needs of Pediatric Oncologists in Complementary and Integrative Medicine: A Cross-Sectional Study

More than one third of all German pediatric patients with cancer use complementary and integrative medicine (CIM). Parents want to discuss the topic of CIM with their pediatric oncologists (POs); however, POs mostly do not feel confident discussing these topics. POs report openness to receiving further information and training, but CIM training opportunities in medical education seem rare. We investigated POs' information and training needs and preference patterns regarding CIM training content with a paper-based or online survey. A total of 101 POs from Germany completed the survey. Only 11.4% agreed to being sufficiently informed of CIM. The participants stated needing further CIM information very often (8.6%), often (38.7%), or occasionally (44.1%). They considered an overview of CIM therapies and information about relaxation methods, herbal remedies, and acupuncture for cancer-related symptoms such as lack of appetite, nausea, or vomiting as most important in CIM training material, and also the topics of adverse effects and summary of evidence. Finally, POs reported on clinical situations in which a need for further information on CIM emerged. The results of our study indicate that there is a need for a structured training that offers knowledge and skills on the subject of patient counseling on CIM in pediatric oncology.

A scoping review of health professional curricula: Implications for developing integration in pharmacy

BACKGROUND

Integrated health professions curricula aim to produce graduates who are capable of meeting current and future healthcare needs. This is reflected in pharmacy education where integration is increasingly advocated by pharmacy regulators as the perceived optimal way of preparing students for registration as pharmacists. There is, however, no definition of integration. Integration can be described according to a model of horizontal, vertical or spiral integration. It can also be described by the themes used to integrate, such as a systems-based approach or by integrative teaching and learning approaches. The level of integration can also be described.

OBJECTIVE

This scoping review aimed to explore health professions education literature to inform the optimal design of integrated pharmacy curricula. This review asks: what is meant by integration in health professions curricula?

METHODS

The Arksey and O'Malley scoping review framework was utilised. Ovid MEDLINE, EMBASE, Scopus, Web of Science and ERIC were searched. Models of integration, themes for integration, integrative teaching and learning approaches, and level of integration were defined and supported data extraction.

RESULTS

There were 9696 records screened and of these 137 were included. The majority of studies (n = 88) described horizontal integration. Systems-based teaching (n = 56) was the most common theme reported. Various integrative teaching and learning approaches were described, including experiential (n = 43), case-based (n = 42) and problem-based (n = 38) learning. The majority of the curricula could be classified as levels 5-7 on Harden's ladder (n = 102). Perception outcomes were reported for 81 studies, and only 3 reported outcomes beyond perception. Reported outcomes were generally positive and included knowledge gains and increased motivation.

CONCLUSIONS

There is a need for integration to be explicitly defined by curriculum developers and researchers. Attention should be given to describing the model, theme, teaching and learning approach and level of integration. There remains a lack of evidence for integration.

Students with an autonomous role in hospital care - patients perceptions

BACKGROUND

There have been calls to enhance clinical education by strengthening supported active participation (SAP) of medical students in patient care. This study examines perceived quality of care when final-year medical students are integrated in hospital ward teams with an autonomous relationship toward their patients.

METHODS

We established three clinical education wards (CEWs) where final-year medical students were acting as "physician under supervision". A questionnaire-based mixed-method study of discharged patients was completed in 2009-15 using the Picker Inpatient Questionnaire complemented by specific questions on the impact of SAP. Results were compared with matched pairs of the same clinical specialty from the same hospital (CG1) and from nationwide hospitals (CG2). Patients free-text feedback about their hospital stay was qualitatively evaluated.

RESULTS

Of 1136 patients surveyed, 528 (46.2%) returned the questionnaire. The CEWs were highly recommended, with good overall quality of care and patient-physician/student-interaction, all being significantly (p < 0.001) higher for the CEW group while experienced medical treatment success was similar. Patient-centeredness of students was appreciated by patients as a support to a deeper understanding of their condition and treatment.

CONCLUSION

Our study indicates that SAP of final-year medical students is appreciated by patients with high overall quality of care and patient-centeredness.

When students struggle with gross anatomy and histology: A strategy for monitoring, reviewing, and promoting student academic success in an integrated preclinical medical curriculum

Gross anatomy and histology are now often taught as parts of an integrated medical or dental curriculum. Although this puts these foundational basic sciences into a wider educational context, students may not fully appreciate their importance as essential components of their medical education and may not develop a sufficient level of competency, as they are not stand-alone courses. The early identification of medical or dental students who struggle with anatomy or histology and the facilitation of adequate didactic support constitute a significant problem in an integrated curriculum. The timely intervention by an academic review board in combination with an individualized faculty-mediated counseling and remediation process may provide an effective solution to this problem.

[Problems in integrative postgraduate medical training of physicians at anthroposophic hospitals in Germany and Switzerland]

BACKGROUND

Anthroposophic hospitals provide integrative medical care by complementing conventional (CON) with anthroposophic medicine (AM). They teach integrative medicine in postgraduate medical training (PGMT). In a first evaluation of PGMT quality in AM, we analyzed the problems of this training from the perspectives of trainers and trainees.

METHOD

We conducted an anonymous cross-sectional full survey of all trainee and trainer physicians at the 15 AM hospitals in Germany (DE) and Switzerland (CH) with questionnaires of the Swiss Institute of Technology (ETH) Zürich, complemented by a module for AM. We also conducted descriptive statistics for questions with answering scales as well as calculations of group differences (two-tailed Mann-Whitney U test) and a qualitative content analysis (Mayring) of free text answers related to the problem analysis.

RESULTS

The response rate in DE embraced 89 out of 215 (41.39%) surveyed trainees and 78 out of 184 (42.39%) trainers; in CH, the response rate comprised 19 out of 25 (76%) trainees and 22 out of 30 (73.33%) trainers. Free text answers related to problem analysis in DE and CH were given by 16 out of 108 (14.8%) trainees and by 20 out of 100 (20%) trainers, overall. Perceived main problems include work overload; shortcomings in work organization; delimitation of competences; interprofessional cooperation; financial resources (trainers); wages (trainees DE); practical relevance of AM (trainees and trainers in DE); professional or didactic competence of trainers; lack of interest in AM (trainees); problems with learning and practicing AM; no curriculum for postgraduate medical training in AM; tensions between AM and CON. Explanations for the differences between DE and CH include larger departments and the DRG system in DE, but also better structural conditions for AM PGMT in CH.

CONCLUSION

Main problems of PGMT in AM include not only non-specific and systemic aspects, but also AM-specific issues. In order to develop a basis for concrete problem solving options, this study will be complemented by an analysis of solution ideas from the perspective of the involved trainers and trainees.

Chinese medicine education and its challenges in the United States

Over the past 4 decades Chinese medicine (CM) has come increasingly into the spotlight in the United States as the clinical effectiveness of CM has been not only empirically well-tested over a long period of time but also proven by recent scientific research. It has proven cost effectiveness, safety, and is authorized for natural and holistic approaches. In consideration, CM is one of the underutilized health care professions in the United States with a promising future. However, CM faces many challenges in its education and system, its niche in the health care system as an independent profession, legal and ethical issues. This paper discusses the confronting issues in the United States: present education, standards of CM education with shifting first professional degree level, new delivery systems of CM education. Development of new research models, training of evidence-based practice, and implementation of integrative medicine into CM education also are the key issues in the current CM profession. This paper also discusses opportunities for the CM profession going beyond the current status, especially with a focus on fusion medicine.

Active student participation may enhance patient centeredness: patients' assessments of the clinical education ward for integrative medicine

Objectives. To examine the impact of active student participation on quality of care in an integrative inpatient setting. Methods. Over a two-year period, we surveyed all patients treated on the Clinical Education Ward for Integrative Medicine (CEWIM), where final-year medical students are integrated into an internal medicine ward complementing conventional medicine with anthroposophic medicine. Patients treated on the regular wards of the same internal medicine department served as the control group (CG). General quality of care was studied with the Picker Inpatient Questionnaire, physician empathy with the Consultation and Relational Empathy measure, and patient enablement with the Patient Enablement Index. ANCOVA was used to control for covariates while examining significant differences between both patient groups. Results. Comparison of the CG wards and the CEWIM revealed no significant differences in medical treatment success. The CEWIM, however, achieved better results for physician-patient interaction, physician empathy, and patient enablement. Eighty Percent of the CEWIM patients rated student participation as positively impacting quality of care. Conclusion. Our results indicate that incorporating students in an integrative healthcare setting may result in greater patient centeredness. Further studies are needed to determine whether this is due to organizational advantages, students' empathic activity, the impact of teaching, or learner-teacher interaction.

The role of health care communication in the development of complementary and integrative medicine

In recent years, complementary medicine (CM) approaches are integrated within a growing number of health care services worldwide. Implementation of CM within primary, secondary and tertiary settings of health care requires attention to a variety of communication challenges. In this special issue of Patient Education and Counseling 23 articles are presented about the patient-provider communication on complementary approaches, and the implementation and integration of CM in health care. Parallel to CM integration in the clinical arena, this special issue emphasizes the importance of two complementary axes: in medical education and in research, particularly on management of chronic illness and life-threatening diseases. The three legs of the integrative stool--research, education, and clinical practice--are perceived in the light of open, non-judgmental patient-health care provider-CM practitioner communication and a patient-centered bio-psycho-social-cultural-spiritual agenda.