Comparative survey of Complementary and Alternative Medicine (CAM) attitudes, use, and information-seeking behaviour among medical students, residents & faculty

There is significant and growing national interest in the introduction and integration of CAM instruction into allopathic medical education, in part supported by recent educational funding from the National Institutes of Health. Interestingly, rates of CAM use by medical students [1] were found to be higher than reported in the US general population in 1998 [2, 3] and 2004 [4]. Tracking change in learner attitudes is one strategy to document successful and effective CAM instruction. However, evaluating CAM curricular impact is complicated by the perceived heterogeneity of trainees' baseline attitudes toward CAM, per se, and the application of CAM to medical practice. A further complication is the absence of reliable, practical, and valid measures of CAM learning outcomes. Although reports have documented attitudes of medical students [5, 6] and nursing, medical and pharmacy students and faculty [7], the surveys used measures that were not validated. Validation studies for two CAM attitude measures recently were reported. The first, the Integrative Medicine Attitude Questionnaire (IMAQ), compared internists attending a conference on holistic medicine to those attending an annual general professional meeting [8]. The second, the CAM Health Belief Questionnaire (CHBQ), was validated by including the IMAQ and using three cohorts (n = 272) of medical students at one institution [1]. The CHBQ was found to have coefficient alpha reliability = 0.75, and total CHBQ attitude scale scores positively correlated with total IMAQ scores (r = 0.71; p < .0005).

The objective of this study was to investigate and compare CAM attitudes, CAM use, and CAM information-seeking behaviours to derive priorities for CAM instruction in medical school and residency. The groups surveyed were (a) medical students, (b) medical and surgical interns at the start of their post-graduate training, and (c) faculty who teach or intend to integrate CAM into their courses or classes. We hypothesized that this selected group of faculty would have more positive attitudes, would themselves use CAM modalities at a high rate, and would use more CAM information resources than either interns or medical students. One of the two student cohorts was surveyed longitudinally in their second and third years of training to track attitude changes, if any, across the continuum of undergraduate medical training.

At the University of California, Irvine (UCI), CAM instruction for medical students at the time of the study was offered in year 1 as a 2-hour panel discussion with patients and CAM practitioners. Subsequent CAM activities were learning issues integrated into problem-based learning cases taught longitudinally across year 1. During one of 4 evidence-based medicine (EBM) classes, students were shown a variety of CAM databases and examples of CAM-related evidence and were required to perform information searches. In year 2 students interviewed at least one patient who used a CAM modality during a community preceptorship and presented the case to peers and faculty with evidence related to that CAM modality. In the third year, students received CAM instruction at noon lectures in two clerkships and were tested for their ability to counsel a patient on acupuncture and use of an herbal for osteoarthritis in the Family Medicine clerkship. Total hours of required CAM instruction across 4 years was approximately 8 hours.

The study was approved by the Institutional Review Board.

The final sample included 667 respondents with 53% (n = 355) medical students, 39% (n = 258) interns and 8% (n = 54) faculty. Response rate for medical student respondents was 96.5%. Response rate for intern respondents was 100%. Response rate for faculty respondents was 60%.

CAM modality use (Figure 2)

Faculty used a significantly higher total number of CAM modalities than either students or interns (F = 26.18; p < .0005). Students and interns did not differ in this regard. Furthermore, faculty were most likely to use each CAM modality. Across the 3 groups of respondents, massage was the most frequently used modality, followed by Spirituality and herbals. The next 3 highest rates of use occurred for meditation, chiropractic and traditional Oriental Medicine. Students and interns were similarly likely to use meditation and chiropractic but their use was lower than that of faculty.

CHBQ scores (Figures 3 and 4)

Mean scores for all 3 respondent groups exceeded (p < .0005) the hypothetical scale midpoint of 35 (i.e., a score representing neutral responses to CAM practice and use). Mean score was highest (F = 24.71; p < .0005) for faculty (54.5) and similar for medical students (47.8) and interns (46.2) (Figure 3). Medical students at 3 different points in their training (years 1, 2 and 3) showed similar (p = .205) mean CHBQ scores (46.4, 47.4, 48.3, respectively; see Figure 4) with no significant change (p = .179) in mean scores for the cohort followed from year 1 to 3.

We conducted a survey of attitudes toward CAM and CAM use that included rate of self-use of CAM modalities and information-seeking behaviors amongst medical students, interns and selected faculty attending CAM workshops. We used a previously validated measure, the CHBQ, to assess CAM attitudes. Not surprisingly, faculty were likely to have more positive attitudes on the CHBQ compared to interns and students. They also demonstrated higher use of CAM modalities than medical students and interns. A notable result was that student attitudes toward CAM and CAM use remained stable and positive and did not deteriorate over the course of training from year 1 to 3 as might be expected from exposure to negative attitudes toward CAM during clinical training. It is possible that our longitudinal integrated instruction maintained positive attitudes toward CAM and CAM use. It is also likely that student attitudes are relatively resilient to change during training. If so, we speculate that CAM instruction could be best directed toward increasing student knowledge of CAM modalities available in their communities and skills to access, appraise and interpret evidence on CAM use, to appropriately advise patients.

The finding of intern attitudes that are as positive as medical students is encouraging and suggests that CAM instruction in residency may be similarly directed toward increasing skill and knowledge rather than changing attitudes.

Our study has some limitations. It was conducted at one institution at which positive student attitudes have previously been demonstrated and may not be generalizable to other institutions and settings. The attitude of other faculty, to whom students are exposed, during four years of training was not elicited. Despite these limitations, our data give cause for optimism and progress in measuring the outcomes of CAM instruction. We conclude that given the stability and positive attitudes of students over the course of training, student and resident instruction in CAM could focus mainly on knowledge and skill acquisition, rather than changing attitudes toward CAM. A comparative study with other medical schools would help to elucidate possible differences in CAM instructional needs across medical schools.