Familiarisation for Medical Students

6.71 Given the increasing popularity of CAM it is important to consider how far medical and other healthcare practitioners should be made aware of the CAM therapies in their training. There are two main reasons why familiarisation is important. First is the belief that doctors should have an understanding of all the health services their patients may be accessing. FIM believe this is particularly important because if doctors do not ask patients about their use of CAM, "there are confounding factors in your delivery of orthodox care…that is bad for the patient" (Q 101). There is an obvious potential for interactions between CAM treatments and conventional medicine. Secondly, medical practitioners (especially general practitioners) are often used by patients as an information source for all health questions. It is therefore necessary, as the Royal College of Physicians told us, for medical students to "have some knowledge of CAM so that they can advise their patients appropriately" (P 190).

6.72 The GMC, whose Education Committee advises medical schools on their curricula, explained that their view towards familiarisation with CAM is positive and that they are actively encouraging medical schools to include this in undergraduate curricula. Professor Graeme Catto, Chairman of the GMC Education Committee, explained: "I think we would want medical students to become familiar with all these techniques, and some, in a sense, are more readily applicable than others, some are already moving into conventional medicine, if you like, and others are far from that. I think the understanding and awareness of what patients may come to young doctors with is helpful in undergraduate medical education" (Q 1037). Professor Catto also said that beyond making sure all medical students had an awareness of CAM there is scope for allowing those undergraduates with a special interest in the area to pursue a deeper understanding of CAM: "Some will want to take that information a stage further and will wish to become involved, through the special study modules, in undertaking some treatments themselves or experiencing, along with patients, what is happening. A further stage then would be through special study modules or related to intercalated degrees. Some may wish to pursue research in these areas".

6.73 Although the GMC believed that familiarisation was important, their evidence confirmed that up until now their guidance in this area has been very vague: "Tomorrow's Doctors[44] presently refers only to the need for medical education to recognise that there is a growing demand for treatments that do not conform to the conventional orthodoxies" (P 96). We were pleased to hear that the GMC are now taking a more proactive role. They explained: "Tomorrow's Doctors is due to be revised in the near future to reflect our view that the universities need to provide some familiarisation with complementary and alternative therapies to students in training".

6.74 We received a wealth of evidence from other witnesses on this matter. The majority (including FIM (Q 1010) and the main professional bodies representing the therapies in our Group 1) have supported the idea that all medical undergraduate courses should include information on CAM.

6.75 The Council of Heads of Medical Schools agree that there is a need for medical education to recognise the growing demand for treatments that do not conform to conventional orthodoxies (Q 245). They gave evidence showing there is enthusiasm for this amongst medical students (Q 243). They stated their position was supportive: "Undoubtedly we perceive interest amongst our undergraduate students in CAM. That is not only in medicine but in other healthcare professions (for those of us who have those within our faculties). The position of the Council of Heads of Medical Schools is that we would be supportive of familiarisation with the philosophy and techniques of CAM in the undergraduate medical curriculum for the prime reason that large numbers of our patients are accessing this form of treatment and it is therefore an important piece of knowledge for undergraduates to have". They proposed that the main scope for programmes of familiarisation lies in two levels: "There should be a small amount of teaching that is for the whole undergraduate corpus, with the ability of those who wish to, to take special study modules and to have more detail on CAM. That is actually quite a common structure amongst United Kingdom medical schools".

6.76 We are aware that there are two approaches familiarisation can take; one is a sympathetic approach to CAM, highlighting its benefits to patients, and the other is an unsympathetic approach highlighting CAM's weaknesses and using it as an example of the dangerous, unproven, unregulated side of healthcare. Both these approaches have been suggested to us. Professor Michael Baum, Professor of Surgery at the Royal Free and University College Hospital, explained that: "As part of the teaching of my medical students I use the claims of complementary and alternative medicine to illustrate the demarcation between science and non-science" (P 243). He assured us he would be outspokenly hostile towards the idea of teaching "alternative medicine" in the undergraduate medical curriculum "other than as an illustration of uncritical thinking" (P 242). However the majority of submissions have suggested that CAM familiarisation should exist so that doctors are aware of their patients' options and can understand why they may be making certain choices. The GMC explained that medical schools teach evidence-based medicine "…so it isn't inappropriate that some schools look at pitfalls related to CAM" (Q 1044). During their regular visits to assess individual medical schools they had found no evidence of any school taking an antagonistic view of CAM.

6.77 We recommend that familiarisation should prepare medical students for dealing with patients who are either accessing CAM or have an interest in doing so. This familiarisation should cover the potential uses of CAM, the procedures involved, their potential benefits and their main weaknesses and dangers.

6.78 During our Inquiry we visited the University of Southampton Medical School and were given a presentation on their familiarisation module: see Appendix 5. We were impressed with the content and approach of the Southampton CAM module and are glad that several other medical schools now offer similar modules. However, overall medical school provision of information on CAM is sketchy. The GMC provided us with some information about the existing provision of CAM familiarisation in some of the other United Kingdom medical schools which were visited during their assessment of Universities' success at implementing the principles set out in the Council's recommendations in Tomorrow's Doctors (see Box 8). This showed significant variation in the extent of CAM familiarisation in United Kingdom medical schools.

Box 8    Extracts from Reports of GMC Visits to United Kingdom Medical Schools 1998-99    Teaching of CAM    " Queen's University, Belfast — A discussion session on alternative medicine forms part of the Science, Society and Medicine module in phase one.    Birmingham — Since 1993 first year medical students have spent one afternoon of their first term with a complementary therapist. This has allowed each student to observe practitioners from two of the following therapies: homeopathy, acupuncture, aromatherapy, reflexology, hypnotherapy and the Alexander Technique, physiotherapy and osteopathy. Students' enthusiasm for these sessions encouraged the School to offer an SSM [Special Study Module] in complementary medicine in Phase 2. This option has proved very popular and has been over-subscribed since its introduction.    Leeds — The School has developed a computer assisted learning (CAL) package on alternative therapies that will shortly become available. The package provides an introduction to a variety of alternative therapies ranging from herbalism and acupuncture to crystal healing. Self-assessment questions are included so that students can test their knowledge and understanding of those therapies.    The SSM Co-ordinator told us that demand from students for SSMs in alternative and complementary medicine had allowed the School to establish links with a range of institutions and organisations involved in this aspect of healthcare. Hence contacts have been developed with the Centre for the Study of Traditional Chinese medicine and the North of England Teaching Centre for the Alexander Technique. Titles of SSMs undertaken by students include "Reflexology and Healthcare Today", "Homeopathy - Principles and practice" and "Traditional Chinese medicine - The Back Shu Points".    We understand the new Health and Illness in Individuals and Populations Integrated Core Unit will include special formal teaching on complementary medicine.    Leicester — The Faculty considers it important that all students should have a good working knowledge of certain complementary and alternative therapies. Accordingly, during Phase I they are familiarised with statutory controlled practices such as osteopathy and chiropractic, and those therapies practised by registered therapists such as acupuncture and hypnotherapy. In the Medical Sociology module consideration is given to the social, cultural and psychological factors which may influence an individual to seek assistance outwith the conventional medical profession.    Newcastle upon Tyne — Some attempts have been made to include this subject within the course. Thus teaching and learning within the Medicine and Society strand promotes an understanding of, and respect for, the health beliefs of individual patients. This programme also considers factors that encourage some people to seek treatments that do not conform to conventional practice. Students are able to undertake SSMs on topics such as "Complementary Medicine" and "The Integration of Complementary Therapies in Medicine into General Practice."    Sheffield — Core teaching in complementary medicine is delivered in Level 5 Lecture Block and Speciality module whilst a Level 1 lecture examines complementary therapies in conjunction with teaching on aspects of neoplasia.    Wales — UWCM acknowledges that little or no teaching is devoted to complementary medicine, though an SSM in this subject is offered….We were told that it was left to the Student Medical Society to organise an event on alternative and complementary remedies available to patients."    Source: General Medical Council (PP 97 - 98).

6.79 We believe that the provision of CAM familiarisation in medical schools is currently too uneven. Some medical schools have well-developed systems for raising CAM awareness in their students, including opportunities for students to observe therapists in action and to attend a small number of lectures as well as the opportunity to take further optional special study modules. On the other hand, other schools have almost no provision for teaching CAM or only briefly mention CAM during lectures on much broader subjects such as Society and Medicine, therefore leaving the task of finding out about CAM to the individual student's initiative. We recommend that every medical school ensures that all their medical undergraduates are exposed to a level of CAM familiarisation that makes them aware of the choices their patients might make. We suggest that all medical schools should consider whether or not to make available optional Special Study Modules in CAM for those students with a particular interest in this area.

Postgraduate Familiarisation for Doctors

6.80 The drive to raise awareness among medical students about CAM is relatively new, so most qualified medical practitioners will not have touched on this subject in their undergraduate training. In order that existing doctors are aware of this area and can advise their patients on their choices, it has been suggested that CAM familiarisation should be included in the Continuing Professional Development of doctors. This is especially relevant for general practitioners and those working in specialities where they are likely to meet patients accessing CAM disciplines (e.g. epidemiologists, allergists, neurologists). Similar arguments apply to dentists and veterinary surgeons. This view was articulated for us by Ms Julie Stone, a Senior Lecturer in Healthcare, Ethics and Law at the University of Greenwich: "As well as tackling this issue prospectively, it is also necessary to provide familiarisation for those doctors and nurses who did not have access to such initiatives in their training. This knowledge is particularly important for GPs, since they are the health practitioners most likely to provide continuity of care. Postgraduate training and Continuous Professional Development might be a useful point at which to introduce such training" (P 288).

6.81 The GMC told us that "the detail of postgraduate training is...a matter for the Royal Colleges and Faculties and the other competent authorities" (P 96). However, none of the Royal Colleges we have heard from discussed this as an activity they are either encouraging or considering.

6.82 However, the University of Oxford Faculty of Clinical Medicine believe familiarisation in CAM for all doctors is important: "Such training is necessary if doctors are to be able to make use of valuable resources in the community, to give informed advice to patients and to be aware of practice that may be harmful and of where to go for information on possible interactions between pharmaceutical drugs and herbal remedies…It should be incorporated into continuing medical education as well as into medical school training" (P 232).

6.83 The British Dental Homeopathic Association pointed out that most dental patients attend for regular examinations which do not always involve any treatment. This places the dental practitioner with an interest in CAM in an ideal situation to discuss aspects of CAM which are related to dentistry. Advice on nutrition is a good example as oral health is directly related to diet. There are also aspects of osteopathy, acupuncture and homeopathy which can be linked to the maintenance of good dental health.

6.84 In their evidence, the General Dental Council (GDC) (P 75) confirmed that: "A number of factors might lead dentists to consider a more holistic approach to patient care than other professionals." Dentists may be involved in CAM in a number of ways and "there are circumstances in which a dentist might provide treatments which could be described as complementary or alternative which themselves amount to the practice of dentistry. For example, such treatments might be in the areas of pain and anxiety control or oral health education which would be regarded as part of a dentist's normal practice. The Council would have no difficulty in unconventional approaches being employed in such circumstances provided that such approaches conformed with the Council's guidance and the public was not put at risk."

6.85 We recommend that Royal Colleges and other training authorities in the healthcare field should address the issue of familiarisation with CAM therapies among doctors, dentists and veterinary surgeons by supporting appropriate Continuing Professional Development opportunities.