Reflecting society’s interest in complementary and alter-native medicine (CAM), most allopathic medical schools in the United States offer instruction in CAM. Pertinent information about the teaching of CAM at osteopathic medical schools is lacking. The authors therefore sought to document the form and content of CAM instruction at osteopathic medical schools and compare their findings with those reported for allopathic medical schools in a recently published survey. Phone conversations with aca-demic officials at each of the 19 colleges of osteopathic medicine revealed that only one school did not teach CAM. With the help of these officials, the authors identified 25 CAM instructors at 18 osteopathic medical schools and sent them questionnaires. All returned a completed form with details about CAM instruction at their schools.
The authors found that CAM material was usually presented in required courses sponsored by clinical depart-ments, was most likely taught in the first 2 years of med-ical school, and involved fewer than 20 contact hours of instruction. The topics most often taught were acupuncture (68%), herbs and botanicals (68%), spirituality (56%), dietary therapy (52%), and homeopathy (48%). Most (72%) CAM instructors were also practitioners of CAM modes of therapy. Few (12%) of the instructors taught CAM from an evidence-based perspective. The authors conclude that the form and content of CAM instruction at osteopathic medical schools is similar to that offered at allopathic medical schools and that both osteopathic and allopathic medical schools should strive to teach CAM with less advocacy and more reliance on evidence-based medicine.
C
omplementary and alternative medicine (CAM) has been broadly defined as “a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine.”1 Consumers are using CAM modes of therapy in ever-greater numbers, and physicians should be trained to recognize the potential for harm some of these modalities pose when used alone or in combination with conventional treatments.2-4 Many patients will want to discuss CAM treatment options with their physicians, and physicians should be sufficiently versed to advise them intelligently. Published surveys indi-cate that allopathic medical schools in the United States have responded to this educational need by incorporating CAM into their curricula.5-7As of 1998, at least 60% of the nation’s 125 allopathic medical schools were teaching CAM topics in required or elective courses.6It is anticipated that this per-centage will grow as advocates of CAM press their case for further integration into the medical school curriculum.8Osteopathic physicians make up an important segment of today’s health care system, though little is known regarding the extent of CAM instruction in the undergraduate training of osteopathic physicians. The purpose of this study is to compare the form and content of CAM instruction at osteo-pathic medical schools with that offered at alloosteo-pathic medical schools. A recent report documenting the teaching of CAM at allopathic medical schools will provide the basis for com-parison.7
The historical arc of osteopathic medicine from a fledgling profession at odds with medical orthodoxy to its present status evinces a successful therapeutic paradigm. But osteo-pathic medicine was once regarded as “alternative,” with considerable opposition from mainstream medicine.9Given this history, we posited that osteopathic medical schools might be more open-minded when dealing with unconven-tional modes of therapy and therefore more disposed to teach CAM compared to their allopathic counterparts. Methods
At the time of this study, there were 19 osteopathic medical schools approved by the Bureau of Professional Education of the American Osteopathic Association (AOA). We collected the names and addresses of academic administrators from the official Web site maintained by the American Association of
Status of Complementary and Alternative Medicine
in the Osteopathic Medical School Curriculum
Dale W. Saxon, PhD; Godfrey Tunnicliff, PhD;James J. Brokaw, PhD, MPH; Beat U. Raess, PhD
Dr. Saxon is an assistant professor in the Department of Anatomy and Cell Biology at Indiana University School of Medicine in Evansville, where Dr. Tunnicliff is a professor in the Department of Biochemistry and Molecular Biology and Dr. Raess is a professor in the Department of Pharmacology and Toxicology. Dr. Brokaw is an assistant dean in the Office of Medical Student Affairs and an associate professor in the Department of Anatomy and Cell Biology at the Indiana University School of Medicine in Indianapolis.
Address correspondence to James J. Brokaw, PhD, MPH, Office of Med-ical Student Affairs, Indiana University School of Medicine, MedMed-ical Science Building, Room 164, 635 Barnhill Dr, Indianapolis, IN 46202-5120.
Table 1 (cont.)
Characteristics of Courses in Complementary and Alternative Medicine (CAM) Taught at Osteopathic
Medical Schools, 2002
Characteristic Respondents, %
Instructional formats used†
Instructor lectures 92 Guest seminars 40 Group discussions 36 Case studies 36 Clerkships 8 Internet-based 16 Other 24
Principal course objective‡
Broad survey of CAM therapies
and concepts 60
Critical evaluation of the scientific
literature regarding CAM 12
Practical training in the use of specific
CAM treatments 20
Other/unspecified 16
Course taught by a CAM practitioner/ prescriber
Yes 72
No 12
Unspecified 16
*Column total exceeds 100% because some respondents taught CAM in more than one year.
†Column total exceeds 100% because most respondents used more than one format.
‡Column total exceeds 100% because some respondents indicated more than one main objective.
CAM indicates complementary and alternative medicine.
Colleges of Osteopathic Medicine.10With the help of these individuals, we determined whether CAM was being taught at their schools and, if so, obtained the names of faculty mem-bers who were involved with the teaching. One administrator reported that no CAM was being taught at his institution, but the other 18 schools we contacted directed us to instructors who taught CAM or had detailed knowledge about CAM topics in their schools’ curricula. A total of 25 instructors at 18 schools were sent coded surveys by US mail, fax, or e-mail. Reminders and a second copy of the survey were sent to all nonrespon-ders after 3 to 4 weeks. Surveys were collected through April 2002.
To enable direct comparisons between osteopathic and allopathic medical schools, we used the same survey instru-ment that was used to collect data for our previous report on CAM instruction at allopathic medical schools.7This two-page survey consisted of nine questions with a check-box or
fill-in-the-blank format. Space at the end was reserved for written comments or clarifications. Questions were asked about year of undergraduate medical curriculum in which course was taught; whether the course was required or elec-tive; whether it was taught by a single instructor or multiple instructors; total hours scheduled for course (20, 20-60, 61-100,
100); name of sponsoring unit; whether CAM practi-tioners/prescribers were involved in teaching; instructional for-mats used (instructor lectures, guest seminars, group discus-sions, case studies, clerkships, Internet-based, or other); principal course objective (broad survey of CAM concepts, scientific evaluation of CAM’s effectiveness, practical training in CAM techniques, or other); and specific topics covered and time devoted to each (selected from a checklist of 19 CAM topics with spaces for additional topics to be provided by the respondent if needed). The survey was designed to be com-pleted in 5 to 10 minutes.
Table 1
Characteristics of Courses in Complementary and Alternative Medicine Taught at Osteopathic Medical Schools, 2002
Characteristic Respondents, %
Type of course
Required 64
Elective 28
Unspecified 8
Course taught with multiple instructors
Yes 72
No 20
Unspecified 8
Year of curriculum in which course was taught* First 60 Second 52 Third 8 Fourth 4 Unspecified 12
Total hours taught in course
20 52
20-60 24
61-100 12
100 12
Type of sponsoring unit
Clinical sciences 60
Basic sciences 12
Other/unspecified 28
offered in the first or second year of medical school. Twelve per-cent of the courses were offered in the third or fourth year.
Half of the courses devoted fewer than 20 contact hours to CAM instruction, but nearly one fourth devoted more than 60 hours (Table 1). Most (60%) courses were sponsored by clin-ical departments, and only 12% were sponsored by basic sci-ence departments. About one fourth of the respondents did not specify a sponsoring unit, which may indicate the involve-ment of several units in a multidisciplinary course.
Lectures by faculty instructors were the predominant means of CAM instruction (Table 1). Guest speakers, group dis-cussions, and case studies were substantially used as well. Eight percent of instructors taught CAM during third- or fourth-year clerkships. The Internet was used to deliver CAM material by 16% of the instructors.
Sixty percent of the respondents reported that the principal objective of their course was to provide a broad survey of CAM and introduce students to a spectrum of topics related to alternative medical practices (Table 1). Practical training in Results
Of the 19 AOA-approved schools we contacted, 18 (95%) were offering some form of CAM instruction in the undergraduate medical curriculum. Of the 25 instructors who were sent sur-veys, all returned completed forms with specific information about CAM instruction at their schools. Thirteen of the schools had a single respondent, four of the schools had two respon-dents each, and one school had four responrespon-dents.
From the 25 returned surveys, we assembled data regarding CAM-related courses taught at the 18 colleges of osteopathic medicine for whom we received responses. Table 1summarizes the salient features of these courses. Two thirds (64%) of the respondents indicated that they taught a required course, with most of the remainder (28%) teaching an elec-tive course. Our survey did not distinguish between courses that were devoted entirely to CAM and those that contained CAM components but were otherwise of a traditional nature (eg, lectures on herbal medicine in a pharmacology course). Most of the CAM-related courses were taught by teams and
0 70 60 50 40 30 20 10 Energy the rapy‡ Reflexology Music the rapy Aromatherapy Chiropract ic Therapeutic touch Hypnosis Massage therapy Guided imagery Biofeedb ack Naturopat hy
Vitamins and supp lements Ethnomedicine † Meditation Other C AM topics* Homeopathy
Herbs and botanicals Spirituality Dietary ther apy Acupuncture Responden ts T eaching T opic, %
Figure.Topics on complementary and alternative medicine taught at osteopathic medical schools, 2002. *Miscellaneous topics not listed, including osteopathic manipulative treatment, which was considered alternative by 16% of the respondents. †Includes topics such as ayurveda, Chinese medicine (excluding acupuncture), and Native American medicine. ‡Includes modes of therapy that use electromagnetic fields, such as magnet therapy.
the use of specific CAM treatments accounted for 20% of the reported course objectives. Few (12%) of the respondents con-sidered a scientific evaluation of CAM’s effectiveness to be a principal course objective. Nearly three fourths of the courses were taught by individuals identified as being CAM practi-tioners or prescribers of CAM modes of therapy.
Of the 19 CAM topics listed in our survey, acupuncture and herbs and botanicals were clearly the most popular, each being cited by 68% of the respondents (Figure). Spirituality (56%), dietary therapy (52%), and homeopathy (48%) were the next most popular. The remaining topics ranged from 36% for meditation and ethnomedicine to 4% for energy therapy. Almost half (48%) of the respondents indicated that they taught CAM topics not included in our survey’s checklist. These topics included “CAM diagnostics and therapeutics,” “new age,” “hyperbaric oxygen therapy,” “integrative medicine,” “mind-body medicine,” “CAM and clinical reasoning,” “CAM and cultural considerations,” and “art therapy.” For the pur-poses of this survey, osteopathic manipulative treatment (OMT) was not considered a CAM treatment modality. How-ever, some respondents (16%) included OMT in their list of CAM topics taught. In these cases, OMT was relegated to “other CAM topics,” as no other suitable category existed.
Not all respondents who taught a topic indicated their time
commitment. Accordingly, there were too few data to accu-rately compute a median number of contact hours for each topic. Inspection of the data revealed that the amount of instruc-tional time devoted to any given topic ranged from 15 minutes to 12 hours. For all topics combined (excluding OMT), the median number of contact hours per topic was 1.0 (n 87).
For the most part, the CAM-related courses taught at osteopathic medical schools were similar to those taught at allo-pathic medical schools affiliated with the American Associa-tion of Medical Colleges.7However, a few major differences were noted (Table 2). Differences were considered major if they were on the order of twofold or greater in magnitude. Compared to the courses at allopathic medical schools, those at osteopathic medical schools were more likely to be required than elective and less likely to be taught during third- or fourth-year clerkships. Basic science sponsorship was min-imal in both settings, but somewhat more common in osteo-pathic medical schools. Whereas most of the courses at allo-pathic medical schools used group discussions, a much smaller proportion of those at osteopathic medical schools did so. However, use of the Internet for instructional purposes, though not substantial in either setting, was more common among osteopathic medical schools.
The topical content of these courses varied (Table 2). The Table 2
Major Differences Between Courses in Complementary and Alternative Medicine Taught at Osteopathic and Allopathic Medical Schools
Osteopathic Allopathic Medical Medical School School Respondents, % Respondents, %* Course characteristic Required course 64 30
Taught in third or fourth year 12 78
Basic science sponsorship 12 5
Group discussion format 36 62
Clerkship-based format 8 23 Internet-based format 16 4 Topics addressed Meditation 36 66 Massage therapy 20 41 Hypnosis 20 40 Therapeutic touch 20 38 Chiropractic 16 60 Energy therapy 4 12
*Data from Brokaw JJ, Tunnicliff G, Raess BU, Saxon DW. The teaching of complementary and alternative medicine in US medical schools: a survey of course directors. Acad Med. 2002;77(9):876-881.
with CAM content were twice as likely to be required at osteo-pathic medical schools than at alloosteo-pathic medical schools. This may indicate a greater commitment to CAM education at osteopathic medical schools, but could just as easily reflect the incidental inclusion of CAM topics into several required courses of the traditional osteopathic curriculum. Another dif-ference is that most CAM instruction at osteopathic medical schools occurred during the first 2 years, whereas CAM instruc-tion during the third and fourth years was relatively uncommon. By contrast, the teaching of CAM at allopathic schools was substantial during the third and fourth years.7In general, these data suggest that students at osteopathic med-ical schools are more likely to be exposed to CAM in required coursework during the preclinical part of their training, whereas students at allopathic medical schools tend to learn about CAM in elective coursework taken during the clinical years.
Despite the dominance of the preclinical years in CAM instruction, the involvement of basic science departments at osteopathic medical schools was surprisingly meager, accounting for only 12% of the sponsored courses. An even smaller proportion (5%) of basic science–sponsored courses was reported for allopathic medical schools.7A related (and trou-bling) finding was that so few of the courses at either type of medical school emphasized a scientific approach to the eval-uation of CAM’s effectiveness. Only 12% of the respondents at osteopathic medical schools and 18% of respondents at allo-pathic medical schools7considered a review of the scientific lit-erature regarding CAM to be a major course objective. This may reflect the fact that most of the CAM instructors were also CAM practitioners, who may lack a critical perspective about the treatments they use and presumably believe in. As the popularity and availability of alternative modes of therapy continue to grow, it becomes increasingly important that physi-cians-in-training appreciate the value of scientific evidence in evaluating claims of therapeutic efficacy. Basic science faculty with expertise in experimental design and statistical analysis of data should be enlisted to help impart a critical balance to the CAM instruction.
As was true of CAM instruction at allopathic medical schools, the CAM topics taught at osteopathic medical schools encompassed a diverse collection of unorthodox beliefs and practices. The five most prevalent topics—acupuncture, herbs and botanicals, spirituality, dietary therapy, and homeopathy— were among the top seven topics taught at allopathic medical schools.7Likewise, the four least prevalent topics—aro-matherapy, music therapy, reflexology, and energy therapy— were also the least prevalent topics at allopathic medical schools.7In general, the emphasis given to a particular CAM topic was comparable between osteopathic and allopathic medical schools.
However, six topics were considerably less prevalent among the osteopathic medical schools (Table 2). The most conspicuous of these was chiropractic, which was taught by proportion of instructors at osteopathic medical schools who
taught about meditation, massage therapy, hypnosis, or ther-apeutic touch was only about half that at allopathic medical schools. Chiropractic was included in relatively few courses at osteopathic medical schools (16%), but was a common topic in courses at allopathic medical schools (60%). Energy medicine was an infrequent topic at both osteopathic and allopathic medical schools, but was more frequently taught at allopathic medical schools. Among the remaining 13 CAM topics, there was less divergence and both types of medical schools pre-sented similar profiles.
Discussion
The present survey and its analysis of CAM instruction at 18 osteopathic medical schools is an extension of an earlier study of CAM course offerings at 53 allopathic medical schools.7 Although the number of completed surveys was necessarily limited (n 25), we believe that our results offer a reason-ably accurate snapshot of the current state of CAM instruction in US osteopathic medical schools. Because of the relatively small number of AOA-approved schools, we were able to make personal contact with an academic administrator at each institution who could help us locate CAM instructors with specific information. This approach enabled us to make direct comparisons with the data collected from CAM instructors at allopathic medical schools.7
Our results indicate that the form and content of CAM instruction at osteopathic medical schools are similar to those offered at allopathic medical schools. We found no evidence to suggest that CAM is more prevalent at osteopathic medical schools than allopathic medical schools. However, this con-clusion is predicated on the assumption that OMT is not a CAM treatment modality. Not everyone would agree with this premise, including some osteopathic physicians. Sixteen percent of our respondents cited OMT as a CAM topic, which indicates a lack of consensus even among osteopathic physi-cians. The National Center for Complementary and Alterna-tive Medicine at the National Institutes of Health considers osteopathic manipulative treatment to be CAM therapy and is currently funding several clinical trials of OMT.11
Osteopathic manipulative treatment and its underlying theory of somatic dysfunction stands as the principal (and perhaps only) inherent distinction between osteopathic and allopathic medicine.12Some studies suggest that OMT use by practicing physicians is on the decline, particularly among recent graduates of osteopathic medical schools.13This has serious implications for osteopathic medicine’s uniqueness as a medical profession. Perhaps external validation from con-trolled clinical trials, such as those now being conducted under government auspices,11will serve to reinvigorate OMT’s posi-tion in osteopathic medical educaposi-tion and clinical practice.
Although we found that CAM instruction at osteopathic and allopathic medical schools was on the whole similar, there were a few notable differences (Table 2). For example, courses
60% of the respondents at allopathic medical schools,7but by only 16% of respondents at osteopathic medical schools. This disparity may reflect the divergent yet related histories of osteopathic medicine and chiropractic. Both professions arose at about the same time and shared certain beliefs, most notably in the therapeutic value of spinal manipulation.12But here the similarity ends. The two systems took different evolutionary pathways after their establishment. Whereas osteopathic medicine developed into a science-based medical profession and moved closer to allopathic medicine in theory and prac-tice, chiropractic retained much of its initial orientation and remained focused on spinal manipulation therapy. Never-theless, the two professions are often confused with each other in the public’s mind, and chiropractic is the better known of the two.14There is an understandable desire by osteopathic physi-cians to distinguish themselves from chiropractors, which may account for some of the respondents’ ambivalence toward teaching chiropractic. Allopathic physicians tend to view osteo-pathic medicine and chiropractic as similar alternative modes of therapy, holding neither in particularly high regard.15The differences exhibited for the other five CAM topics were less dramatic and may reflect the individual interests of our small number of respondents compared to the larger data set from allopathic medical schools (n 73).7
Summary
We found that the typical CAM course taught at colleges of osteopathic medicine was a team-taught, required course sponsored by a clinical department. It was most likely to be taught in the first 2 years of medical school, have fewer than 20 contact hours, and use lectures as the primary instructional format. The course was probably taught by proponents of CAM modes of therapy who might not be disposed to impart a critical, evidence-based perspective. It was most likely a survey course designed to introduce students to a broad array of popular CAM topics, such as acupuncture, herbs and botan-icals, spirituality, dietary therapy, and homeopathy. Other than the notable differences discussed previously, these course descriptors are similar to those reported for CAM courses at allopathic schools.7
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