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Integrative Family Medicine Program

Maine Medical Center Family Medicine Residency Program
Complementary and Integrative Medicine Project

Methods
General

We propose a 30-month project, including planning, implementation and evaluation stages. Most of the curricular planning and faculty development will occur in year one, with implementation of the curriculum in year two. Evaluation and refinement will be concurrent with implementation in year two, and final evaluation and dissemination will occur in the final six months of the grant period. The program director will convene and chair an Advisory Committee comprised of one faculty member for each of four designated area of CAM (acupuncture, mind-body interventions, homeopathy/herbal remedies and manipulative therapies), several family practice residents, a community practitioner for each designated area of CAM as well as other community CAM providers (naturopath, energy therapist, hypnotist), faculty expert, faculty coordinator, our Learning Resource Center health educator, one of our practice RNs, patients and community members. The responsibilities of the Advisory Committee, with leadership from the program director, will include identifying community resources, reviewing, approving and evaluating the CAM curriculum, planning educational workshops for faculty, residents, FPC staff and community family physicians, and planning for dissemination of our project results within our institution and nationally. The Advisory Committee will meet monthly during the planning period of the project and quarterly after the first project year.

Methods to support Aim 1: Development of a CAM curriculum for resident
In the process of developing our curriculum in CAM, we will use both the process and the written format we have been using and refining since 1993, described in detail on later pages. The program director, faculty expert and faculty coordinator, with the Advisory Committee, will review the current literature regarding use of CAM by patients and education about CAM in residencies and medical schools. We will identify national consultants regarding CAM, and sponsor workshops for faculty, staff and residents.

Once we have furthered our own understanding of CAM, we will develop objectives for knowledge, skills and attitudes in selected areas of CAM. We envision a one-day curricular planning retreat for the faculty expert, faculty leaders, the community practitioners and residents, with the program director and faculty coordinator assisting in the process. After identification of the knowledge, skills and attitudes for each area, the group will identify the learning experiences, didactic and experiential, longitudinal and block, which will allow the residents to attain the objectives. We anticipate the development of a curriculum integrated into all the aspects of current resident education: an introduction in orientation, perhaps including first-hand experience with the modalities; a block rotation working with community and/or faculty CAM providers; longitudinal education through teaching conferences and workshops and a web-based teaching module; and educational sessions in conjunction with patient care at the FPCs. During the implementation phase, our faculty expert and coordinator will coach residents and preceptors in the outpatient setting, encouraging application of CAM therapies for conditions commonly treated in the FPCs.

The curriculum-planning group will identify resources, including teachers, computer software, books and journals for each element of the CAM educational program. The faculty expert will share his knowledge of national and web-based resources for practice and education of CAM. As they review possible resources for the curriculum, the faculty will bring their informatics and EBM critical appraisal skills to bear, finding information from a variety of sources, selecting the references and identifying the teachers with the most evidence-based validity.

We will implement our new curriculum at the beginning of the second grant year. Each of seven residents in one class will complete any block rotation components during that year. All residents will be exposed to the longitudinal components like precepting, teaching conferences and workshops, and interaction with CAM providers, the faculty expert and faculty leaders in the FPCs throughout the project period.

Residents will evaluate each aspect of the curriculum as they complete it. Current evaluation tools include resident self-assessments about their knowledge, skills and attitudes and opportunities for them to outline learning goals in each aspect of the curriculum. During the first implementation year, the program director, faculty coordinator and faculty expert will work together closely to refine any aspect of the curriculum that can be improved. At the end of the first year of curriculum implementation, the Advisory Committee will meet with the residents and carry out an oral comprehensive review of the first year's experience. From the written and oral evaluations, the Advisory Committee will recommend curricular changes for the future. Surveys of our program graduates, and patient and staff assessment of the degree to which they see improvement in integration of CAM therapy in the residents' practice will offer important evaluative information for our curriculum.

Methods to support Aim 2: Engagement of a faculty expert and development of faculty leaders
We propose to engage a physician who is fellowship trained in CAM to work with us on this project. Having an expert with deep understanding of the philosophy, practice, ethics and economics of complementary and alternative therapies will help ensure the attainment of all of our aims. His knowledge of issues related to CAM will help us shape a balanced curriculum and identify resources for teaching CAM. His presence within our residency program will foster interest and encourage our faculty leaders in their roles. His ability to "speak their language" will allow for more fruitful dialogue with our four community CAM mentors, and with other CAM providers in the community. Finally, his training as a family physician with added qualifications through his fellowship will help him promote understanding and garner support for education and practice within the FPCs and MMC. Research and patient care, including provision of selected CAM services, will ensure credibility in our traditional medical institution.

We have identified four faculty leaders for this project, each of whom will focus on one aspect of CAM: acupuncture, herbal/homeopathy, manipulative therapies or mind-body interventions. We expect the faculty leaders to become knowledgeable in their chosen content area, serving as resources for education and curricular planning for the rest of the residency. Each faculty member will attend a seminal national conference in his or her area of interest during the period of the grant. They then will continue to refine knowledge and skills through a unique mentoring process in which they are paired with local CAM practitioners and the usual continuing medical education process supported by the Department of Family Medicine. The faculty expert will assist as an in-house expert, offering guidance and support to the faculty leaders. Some of the faculty leaders will attain certification and provide CAM services themselves, others will develop the in-depth knowledge needed to teach about the modality and to refer most effectively.

Family practice residents in our program learn, in large part, through the day-to-day contact with faculty physicians who serve as role models. With enhanced understanding of CAM, the faculty leaders will effectively model a practical level of understanding of CAM and the integration of CAM techniques into their patients' care. This integration may take the form of services they themselves provide or through a more sophisticated understanding of services provided by community CAM providers to whom they refer.

Pairing with local CAM providers as mentors, each faculty leader will have an opportunity, on a longitudinal basis, to enhance and maintain the skills and knowledge they attain through conferences and workshops. Each faculty leader will spend one half-day weekly working on this project throughout the first 18 months of the grant period, some of the time working on curriculum and workshop development, some in the mentoring component, and some developing resident didactic sessions and identifying the resources which will support the residents' curriculum. Each faculty leader will work with his or her local CAM provider mentor and our faculty expert to develop the didactic curricular components for residents. As teachers, the faculty leaders will be driven to keep abreast of new developments and reinforce their own knowledge. Finally, the faculty members will maintain skills and knowledge as part of their own practices with patients, again, either on the basis of services they themselves provide, or through appropriate referral to and integration of the services of community CAM providers. The presence of CAM providers, including our faculty expert, within our FPCs will be especially helpful, providing opportunity for informal and formal consultation with the faculty leaders. Our faculty expert and leaders will integrate CAM expertise in teaching in the outpatient setting. In their roles as preceptors, they will discuss on a case-by-case basis the potential use of CAM in diagnosis and treatment of typical outpatient conditions, and will review indications for CAM therapy and appropriate use of referrals to CAM providers.

Faculty leaders will use their skills in information retrieval and critical appraisal, recently sharpened through our faculty development efforts in informatics and EBM to identify and collate computer-based resources in CAM. We expect the CAM curriculum to include a collection of web-based resources, references and teaching modules which we will organize on our web-site for residents, faculty, community physicians and others at MMC, and accessible to those outside our institution as well.

Our faculty expert and four faculty leaders in the curriculum development project will need informed colleagues to carry out the project objectives. With national experts and the Advisory Committee, they will develop the four local workshops in CAM. The workshops will introduce the residency faculty, residents, staff at the FPCs, and interested others from MMC to concepts and practice of the four designated aspects of CAM. The development of a shared vision and understanding of the project goals among those who work with residents on a daily basis is a critical element in the success of our residency curriculum. This shared vision is predicated upon a basic understanding of the principles and practice of CAM modalities which we expect to result from participation in the workshops.

Methods to support Aim 3: Development of collaborative relationships with CAM practitioners
To integrate CAM fully as a curricular theme in our program, we need to bridge the current chasm between CAM practitioners and medical educators in our community. We have invited a community CAM provider in each of the four designated areas to collaborate in an innovative partnership with us on this project. Grant funding will support CAM practitioners' time away from their own practices as they work with us. Each will serve on our Advisory Committee, as a paid "member of the board." Each community practitioner will be funded for the daylong curriculum planning retreat and will attend the CAM workshops with national consultants. Through their grant-supported mentoring of our four faculty leaders, the CAM practitioners, as experts in their fields, will have an ongoing opportunity to educate our traditionally trained faculty.

To expose our faculty, residents, staff and patients to CAM practice in more depth, we will offer office space and equipment to these practitioners, free of charge, during the period of the grant. Community CAM practitioners will bill patients for their services, and any revenue resulting from their services will go to the community CAM providers. Support for visits with CAM providers for uninsured patients and those who cannot afford to pay out-of-pocket will be provided through the MMC uncompensated care program. In the FPC, the CAM practitioners will see patients, either self-referred or referred by their faculty or resident family physicians. We expect that the sports medicine faculty and fellows will refer patients frequently for manipulative therapy, acupuncture, guided visualization and other modalities used in recovery from sports injuries, enhancing athletic performance and treating chronic pain. We anticipate that the camaraderie that develops through practice in the same site will persist, that our patients will embrace the integration of CAM with their more traditional care and that we will continue to offer many some of the same services far into the future.

Our faculty expert, with his background in integrative medicine, is a natural link between our program and the local CAM community. He will engage several of the local CAM providers in dialogue about practice and invite them to collaborate in resident education. With faculty, they will provide lectures and expose residents to CAM techniques with patients in their own offices and at the FPCs. We recognize the importance of including practitioners from multiple disciplines and backgrounds to participate in our project. We will include community representatives in fields such as energy therapy, naturopathy, and oriental medicine to work with us on the Advisory Committee. We expect that as we build teaching and referral relationships with more and more local CAM practitioners we will develop opportunities for them to provide services within our office settings.

Methods to support Aim 4: Development of an environment conducive to CAM through educatio
Our faculty, staff, residents and patients, like many across the country, are open to new models of care, but suffer from a lack of understanding of many aspects of CAM. To promote the CAM curriculum and to integrate it into our residency training and practice, we must educate our faculty, residents and staff about CAM. We plan four half-day workshops and a preliminary overview seminar. These conferences will allow a multidisciplinary approach to education, enabling the residents themselves, the physician faculty and the RNs involved in resident education to learn together.

One of the key aspects in acceptance of CAM practices is a reconciling of the traditional medical model, based on western science, with a different paradigm used in many CAM modalities. We anticipate a preliminary session will provide an overview of CAM. Key areas in this overview include: the paradigm shift from traditional medicine to CAM; issues of assessing validity of treatment approaches; and issues the conventional practitioner faces frequently: protecting patients from the risks of CAM, permitting use of nonspecific therapies, promoting safe and effective CAM therapies and partnering with patients about CAM.15

The four half-day workshops will focus on acupuncture, herbal remedies and homeopathy, manipulative therapies and specific mind-body therapeutic techniques. In addition to national consultants, the faculty expert, faculty leader and community CAM provider will play a role in presentation in the conferences. Insofar as possible, we will use real-time demonstration, case-based and experiential learning in the conference setting. Patient panels will help educate their physicians about not only the efficacy of their use of complementary medicine but also about the reasons conventional medicine did not meet their needs. For each CAM modality, the workshop will cover the knowledge set outlined by the Society of Teachers of Family Medicine in their suggested curriculum guidelines:

  • Prevalence and patterns of use of the modality
  • Legal issues regarding referral and collaboration
  • Current status of insurance reimbursement
  • Applications of the principles of evidence-based medicine to the study of CAM
  • Training, licensing and credentialing standards
  • Basic philosophy/theory of the discipline
  • Common clinical applications and indications for referral
  • Potential adverse effects
  • Reputable references for more information
  • Current research evidence for efficacy and cost-effectiveness, including an awareness of the methodological issues and difficulties raised in studying the modality

Each workshop participant will complete a written evaluation of each workshop.

Though we expect to be leaders in the development of a CAM curriculum within MMC, we acknowledge the importance of the broader institutional community in developing an environment conducive to residents' learning about CAM. The MMC CAM Task Force report from 1998 attests to the institutional appetite for increased provision of CAM services, and a need for further institutional education. We are positioned to help others in our institution with the educational process. We have experience in being institutional leaders about "cutting edge" models of care; we have been acknowledged as leaders in informatics and EBM. As that project draws to a close, we have been asked by the president of the medical staff to assist in bringing the concepts and skills in informatics and EBM to a broader physician audience at MMC. Though on a limited basis, we do expect attendance at the workshops by those outside our department. We will educate other residency program directors and chiefs of departments through brief presentations at their meetings. One of our goals is to convene the permanent institutional committee recommended by the 1998 CAM Task Force to address the issues of provision of those services

Development of relationships with CAM consultants will help us foster an environment conducive to learning about CAM. We hope to achieve a level of familiarity and trust by working side by side with CAM practitioners within our FPCs. Their presence will support informal dialogue between them and residents, nurses, faculty and patients that will help reveal unforeseen barriers, questions and concerns that may not be addressed in more formal conference settings.

Finally, we see our environment as a national one, and expect to share our curriculum with other residency programs, not only within MMC, but also statewide, regionally and nationally. We will present results of our project at the Society of Teachers of Family Medicine conference and publish in their journal, widely read by family medicine educators. Our web-site with teaching modules and organized links to reputable CAM sites and resources will be available to others on-line.

Potential problems
We acknowledge several potential problems as we propose this project. One of the most obvious is the possibility that one or more of our faculty members or residents refuse to approach CAM with an open mind. Despite having voiced acceptance of CAM education as a group, there may be individual faculty members who passively or actively resist its inclusion in our curriculum. The lack of buy-in by even a few residency personnel can undermine innovative efforts. The program director will work with the faculty expert, faculty leaders and the Advisory Committee to develop the shared vision needed for success. One element of the development of the vision is to sound out personnel about their views, expose resistance and gently encourage understanding and acceptance of the potential usefulness of CAM modalities.

Another potential problem is the current saturation of the curriculum. Each resident uses elective time to shape his or her education to meet the needs of his or her future practice. To maintain maximum curricular flexibility with elective time, we must remove a current curricular element if we add a new block rotation. Our accrediting board mandates many of the block rotations, so it becomes difficult to eliminate one rotation to make way for other block experiences. In the past, we have used a group process including faculty and residents to make major curricular changes. We anticipate that CAM will be added to our curriculum in a similar manner, with group consensus.

Our first choice as faculty expert, Dr. Craig Schneider, will finish his fellowship in integrative medicine in June 2001. We have made a tentative agreement with him regarding a role on this project, but until grant funding is secure, we cannot make a firm commitment to him. If he does not join us, we will recruit another physician with similar qualifications to serve as our faculty expert, and will provide him or her with an orientation to our residency program and community to ensure his or her effectiveness in the role.

Finally, our faculty, like those in all other institutions, has multiple demands on their time and energy. They must pursue scholarly activity, attend to clinical productivity and teach. The program director will dedicate time for CAM for the faculty expert and for each faculty leader and will support them in prioritizing their work in CAM.

Institutional commitment and methods to sustain our efforts
We have institutional support from the President of our Medical Staff, the Vice-President for Medical Education and the Chief of the Department of Family Practice as reflected in their letters of support. The Department of Family Medicine is committed to the project and will allocate to the faculty expert, each of the four key faculty members and the program director the time designated to carry out the project objectives. The full resources (secretarial, equipment, computers) of the Department are at the disposal of the project personnel.

More specifically, institutional support will provide us with the following resources, available through the project period and beyond:

  • Direction, vision and promotion of the project by Dr. Skelton, program director. Estimated effort 10% over the entire project period.
  • Learning Resource Centers at both FPCs:
    • Health educator's participation in the Advisory Committee meetings
    • Patient education materials to support education and decision making regarding CAM
    • Health educator's patient education services on an individual and group basis regarding CAM
  • Administrative support for program director and faculty leaders
  • Patient care support for each CAM provider, once monthly or more, over one year:
    • Medical assistant, receptionist
    • Medical supplies, exam table paper, etc.
  • Office space, personal computers for all personnel

Dollar amounts for these resources are estimated at over $100,000, and are detailed in the budget justification.

To be successful with this project, we must be able to sustain the curriculum and enthusiasm for the subject matter beyond the grant period. The experience and leadership of the program director, faculty expert, faculty coordinator and the work of the Advisory Committee will sustain the initiative into the future. Dr. Skelton, the program director, as Program Director of the MMCFPRP, has developed many new curricular areas over the past five years. She chaired the COPC task force for our first grant-supported curriculum project, and is the project director for our current faculty development project in informatics and EBM, which is nearing completion. Each effort has been successful, and there is no doubt that this new area of curriculum will be incorporated into the FPRP in a similar manner. Craig Schneider, M.D. , our faculty expert, completed his residency at the MMCFPRP in 1999. His first-hand knowledge of our faculty, our community, our patients and our institution will facilitate his leadership in this project, allowing him to progress toward meeting and sustaining our objectives much more quickly than someone unfamiliar with our program could. During the three-year project, he will build a practice integrating family medicine and CAM and will develop his teaching role during the 25% of his time supported by MMC. He will expand those roles after the project period and will remain a member of our faculty well beyond the period of grant support. Our faculty coordinator, Cynthia Cartwright, has worked with us for seven years as an educational consultant and member of our Curriculum Committee. Most recently, she has coordinated the informatics and EBM project. In this role, she has coached faculty and residents in the use of informatics and EBM; she will use those skills with faculty and residents in exploring potential uses for CAM. The Advisory Committee, like the task force in each prior project, will help the project personnel gain broad-based support from faculty, residents, community practitioners and the wider MMC institutional community. The Advisory Committee will help address unforeseen problems and make sure the project is carried through to completion. The mentor system for our four key faculty members will provide them with ongoing support, encouragement and skill refinement as they gain expertise in each of the designated areas of CAM.

 

 


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