Family Medicine Program

Academic Medicine, Vol. 81
543
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Дата публикации: 2012-02-07
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Integrative Medicine The Integrative Family Medicine Program: An Innovation in Residency Education Victoria Maizes, MD, Howard Silverman, MD, MS, Patricia Lebensohn, MD, Mary Koithan, RN, PhD, Benjamin Kligler, MD, MPH, David Rakel, MD, Craig Schneider, MD, Wendy Kohatsu, MD, Meg Hayes, MD, and Andrew Weil, MD Abstract The Integrative Family Medicine (IFM) and family medicine residency programs program. Evaluation is performed jointly: Program is a four-year combined family at Beth Israel/Albert Einstein College of PIM evaluates the residents during medicine residency program and Medicine (AECOM), Maine Medical residential weeks and through online integrative medicine fellowship. It was Center, Middlesex Hospital, Oregon modules and residency faculty members created in 2003 to address the needs of Health & Science University, and the perform direct observation of care and four constituencies: patients who desire Universities of Arizona and Wisconsin. review treatment plans. Preliminary data care from well trained integrative One or two residents from each of these suggest that the program enhances physicians, physicians who seek such institutions may apply, and when interest amongst graduating medical training, the health care system which selected, commit to extending their students in family medicine training. The lacks a conventional integrative medicine training by a fourth year. They complete Accreditation Council of Graduate training route, and educational leaders in their family medicine residencies at their Medical Education Family Medicine family medicine who are seeking new home sites, enroll in the distributed residency review committee has awarded strategies to reverse the declining learning associate fellowship at PIM, and the pilot experimental status. interest in family medicine amongst U.S. are mentored by local faculty members graduates. The program was designed who have training in integrative Acad Med. 2006; 81:583–589. jointly by the University of Arizona medicine. To date three classes totaling Program in Integrative Medicine (PIM) twenty residents have entered the T he Integrative Family Medicine (IFM) educational leaders in family medicine treatment plans. To date three classes program is a new model for residency who are seeking new strategies to reverse totaling twenty residents have enrolled in training that combines family medicine the declining interest in family medicine the IFM program. residency and integrative medicine amongst U.S. graduates. fellowship programs. Participants in this program are trained in the philosophy Family medicine residents at six pilot Background and practice of integrative medicine, sites around the country can apply during Patients use complementary and which is defined as “healing-oriented their first year of residency to participate alternative medicine (CAM) in large medicine that takes account of the whole in the IFM program. Each year, one or numbers. The most recent data reported person (body, mind, and spirit), two residents per site are selected and by the Centers for Disease Control and including all aspects of lifestyle. It agree to extend their family medicine Prevention reveals that 62% of the U.S. emphasizes the therapeutic relationship training from three to four years. They population uses CAM.2 A qualitative and makes use of all appropriate complete their entire family medicine study of women with breast cancer (in therapies, both conventional and residency at their home site. In addition, which 72% were using one or more CAM alternative.”1 IFM was created jointly by in their second year of residency they therapy) revealed that the women valued six institutions (see details below) to enroll as associate fellows in a 1,000-hour their physicians’ respect and address the needs of four constituencies: distributed learning fellowship in understanding regarding treatment patients who desire care from well- integrative medicine taught by the choices. However, these women mostly trained integrative physicians, physicians University of Arizona Program in perceived their doctors would not be who seek such training, the health care Integrative Medicine. IFM residents learn interested in their use of CAM, would system (which lacks a conventional integrative medicine from University of respond negatively, or would be unable integrative medicine training route), and Arizona faculty during three residential to offer any useful information.3 A survey weeks in Arizona and from the online of parents revealed that 75% of those curriculum and are mentored by their who used CAM themselves and 81% of Please see the end of this article for information about the authors. local residency faculty who have training those who used CAM for their children in integrative medicine. Evaluation is would like to discuss CAM therapies with Correspondence should be addressed to Dr. Victoria Maizes, Executive Director, Program in Integrative shared; the University of Arizona carries their pediatrician.4 Medicine, Associate Professor Clinical Medicine, out evaluation activities during Family and Community Medicine, and Public Health, residential weeks and in online modules, Most physicians however, feel University of Arizona, PO Box 245153, Tucson, AZ 85724; telephone: (520) 626-6417; fax: (520) 626- and residency faculty members perform unprepared to answer questions about 3518; e-mail: (vmaizes@ahsc.arizona.edu). direct observation of care and review of CAM. A survey of Colorado physicians Academic Medicine, Vol. 81, No. 6 / June 2006 583

Integrative Medicine found 60% thought they needed to learn Selection of primary care residency the whole person,” “a generative impact more about CAM to adequately address training has declined significantly on patients’ lives” so that physicians may patient concerns.5 A survey of Canadian amongst graduates of U.S. medical foster the personal growth of their family physicians revealed that 71% were schools.14 After steady increases in patients and assist them in achieving interested in evidence-based CAM interest in family medicine from 1992– improved health and wellness, “a talent information, and 69% agreed that 1997, the trend reversed between 1997– for humanizing the health care physicians should be knowledgeable about 2005. For example, the percentage of experience,” “a natural command of CAM.6 Medical students want CAM to be graduating U.S. medical students complexity,” understanding the included in their training.7 Although choosing family medicine in the National physician’s role as being more than that medical schools have begun to incorporate Residency Matching Program (NRMP) of a provider of “pills and procedures,” some training in CAM, it is predominately shrank from 16% in 1997 to 7.7% in and “a commitment to multidimensional offered as electives and often not well 2005. In 1997, 3,262 family medicine accessibility,” including good integrated into the curriculum.8 residency positions were offered and communication with all those involved in 2,340 (71.7%) were filled with U.S. the patient’s care. These characteristics Integrative medicine educational graduates.15 In 2005, 2,782 positions were are significant features of integrative programs are growing in number. The offered in family medicine and 2,292 medicine training, thus strengthening the National Center for Complementary and (82.4%) positions were filled through the impetus for the IFM program. Alternative Medicine has funded fifteen NRMP; however, only 1,132 (40.7%) R25 educational grants to incorporate were U.S. graduates. Many of the international graduates return to their Creation of the IFM Program CAM into medical, nursing, and residency training.9 The Consortium of native countries to practice, reducing the The IFM program was jointly created in Academic Health Centers for Integrative supply of primary care physicians in the 2003 by faculty at the University of Medicine now has 31 member United States, especially in rural areas.16 Arizona Program in Integrative Medicine institutions, most of whom have and by family medicine faculty from Beth significant educational programs in Several recent studies commissioned by Israel/AECOM (New York, New York), integrative medicine.10 Learning the American Academy of Family Maine Medical Center (Portland, Maine), Physicians (AAFP) explore the declining Middlesex Hospital (Middletown, objectives in CAM for medical students interest in family medicine. One study Connecticut), Oregon Health & Science and residents have been published.11,12 A surveyed graduates of 24 U.S. medical University (Portland, Oregon), the recent Institute of Medicine report schools regarding their specialty choices University of Arizona (Tucson, Arizona), emphasized the need for all physicians to of family medicine, internal medicine, and the University of Wisconsin become familiar with CAM approaches medicine, and pediatrics. The study (Madison, Wisconsin). These six sites so they can properly counsel their found that students were concerned were selected with diversity and patients regarding their use.13 about their ability to develop competency generalizability in mind and include in the broad scope of family medicine urban and suburban, community, and Although many medical schools and with only three years of training.14 university-based programs. All sites have residencies have sought to incorporate training in integrative medicine into their faculty trained in integrative medicine The AAFP, the American Board of Family to provide onsite mentoring and curricula, they have faced significant Medicine, Association of Departments of supervision of residents. The department barriers.11 Availability of faculty trained Family Medicine, Association of Program chairs promised to provide salary support in the field, the already crowded Directors of Family Medicine, the North for the IFM residents who would be curricula, and the additional expense American Primary Care Research Group, extending their residency training by a have limited the extent of such training. and the Society of Teachers of Family fourth year and to support their identified A satisfactory model for the Medicine commissioned a multipart faculty member’s time on the project. incorporation of substantial training in national study that resulted in a report integrative medicine into conventional about the future of family medicine.17 To The curriculum and evaluation processes medical education has yet to emerge. enhance the training of family physicians, were devised during onsite retreats and Most programs are either elective or the authors recommend that the school’s monthly conference calls. The curriculum continuing medical education/ Residency Review Committee (RRC) balances uniformity of training with fellowship-level programs reaching only a “permit active experimentation and flexibility and consists of core requirements small number of physicians-in-training. ongoing critical evaluation of and elective activities. The implementation The IFM program was designed to competency-based education.” One of the curriculum is flexible so that diverse address these barriers. The portability of suggested experiment was to extend residency programs can incorporate the the University of Arizona associate family medicine training to four years. program into their existing structures. fellowship program (described below), During the first faculty retreat in September the comprehensive curriculum, the The report offers recommendations for a 2003, two overall goals were established for decision by the six family medicine new model of practice and training the program: residency programs to extend training to in family medicine. Specific four years, and funding by the United recommendations include a focus on 1. The program will be developed and States Department of Education, made developing and strengthening key implemented so that it can become an the creation of the pilot version of the attributes of family physicians such as “a accredited model for a four-year IFM program possible. deep understanding of the dynamics of program that integrates training in 584 Academic Medicine, Vol. 81, No. 6 / June 2006

Integrative Medicine integrative medicine with residential fellowship program was after 1.5 years of family medicine conventional family medicine launched.18 The residential fellowship residency training). Clinical supervision residency training. was designed as a “train the trainer” takes place at the individual residency model and was limited to four fellows per sites, and residents are mentored by the 2. Graduates will manifest the year. While many of the graduates have selected faculty expert. Thus the IFM philosophy and practice of integrative become academic leaders of integrative program is a hybrid of the residential and medicine. medicine programs, the need for a larger associate fellowship programs at the It was also decided that the Program in training program was clear. In 2000, the University of Arizona and incorporates Integrative Medicine associate fellowship Program in Integrative Medicine adapted aspects of both programs. Further training program at the University of its curriculum and initiated a two-year characteristics of the IFM program’s Arizona would be used as the primary distributed-learning associate fellowship curriculum are described in List 1. curricular delivery approach. The program. In brief, the curriculum provides a strong Program in Integrative Medicine initiated IFM program residents from the six pilot knowledge component via the associate development of a comprehensive fellowship, a clinical component in the curriculum in integrative medicine in sites join the larger associate fellowship outpatient setting with continuity as well 1994. Three years later, a two-year class in January of their second year (i.e., as consultation sessions and case conferences, an experiential component, List 1 opportunities to learn about other Characteristics of the Integrative Family Medicine Program Curriculum, 2006 modalities and in-depth training in one of them, and a reflective, self-care Residents in the Integrative Family Medicine Program participate as Associate Fellows in the University of Arizona Program in Integrative Medicine. component that emphasizes the embodiment model of integrative 1. This program is a two-year Web-based curriculum in integrative medicine. Learning occurs medicine. The IFM program is designed through interactive content and exercises on the Internet site, threaded dialogues, reading and CD-ROM assignments, in-home herbal, acupuncture, and homeopathy labs, and community to extend the current family medicine assignments. The program includes three residential weeks in Tucson designed to build paradigm beyond the biopsychosocial community among the participants, as well as to provide hands-on experience with integrative model. The goal is not to create a new medicine. family medicine subspecialty or 2. The residents are expected to spend an average of six hours a week studying the online certificate of added qualification; rather, curriculum. it is to educate family physicians who Integrative medicine is gradually incorporated into the outpatient setting with faculty supervision. practice medicine in an integrative manner. 1. Residents apply the principles of integrative medicine in their continuity clinics. In addition to the 1,650 required patient visits in residency years 1 through 3, fellows continue their Once the program goals and values were continuity care clinic in the fourth year. adopted and the basic curricular 2. In the fourth year fellows participate in an integrative consultation outpatient service. They see assumptions and framework were patients referred to them from other clinicians and offer comprehensive evaluation and outlined, the faculty met for a second treatment plans. retreat in 2004 to further refine core 3. Fellows must have a minimum of 50% clinical activities in the fourth year. programmatic components and develop an evaluation strategy. Behavioral Self-care is emphasized and incorporated as a core part of the curriculum. competencies (List 2) were identified 1. In consultation with faculty, each trainee will establish and periodically update a self-care after reviewing recently proposed wellness plan to establish a balance between professional activity and personal well-being. integrative medicine core competencies 2. Time will be allotted for implementation of the trainees’ self-care wellness plan. for medical school curricula4 and the 3. Reflection activities will be regularly scheduled to explore the process of becoming an general residency competencies of the integrative family physician. Accreditation Council for Graduate Medical Education (ACGME).19 Fellows are expected to develop competency in defined core curricular areas, learn different modalities in integrative medicine, and to select one modality for more in-depth training. An evaluation plan was designed to Experiential learning is emphasized, including experiencing treatment modalities. address the decentralized nature of the Fellows have responsibility to teach and perform scholarly work, including presentation, research, IFM program and the diversity among and publication. implementation sites, focusing on (1) the core programmatic competencies, (2) the Fellows perform some kind of community service. curriculum design, and (3) the potential Additional teaching methods include (but are not limited to): impact of the IFM program on the family 1. Integrative medicine patient care continuity experience medicine residency environment. Evaluation strategies (List 3) were 2. Continued primary care continuity clinic through all four years of training selected based on faculty experience with 3. Integrative medicine consultation clinical experience in the fourth year the measures, a review of the evaluation 4. Regularly scheduled multidisciplinary case conference literature, recommendations from the ACGME Outcomes Project, and Faculty trained in integrative medicine who embody the philosophy of practice of integrative measures currently used in the medicine are actively involved in training and mentoring. participating family residency programs. Academic Medicine, Vol. 81, No. 6 / June 2006 585

Integrative Medicine more applicants to the participating List 2 residencies and to assess the quality of Core Competencies to be Achieved by Residents in the Integrative Family those applicants. Medicine Program, 2006 1. Practices self-care. Data were collected from the residency 2. Demonstrates self-awareness. program directors of each participating site immediately after the Match. Four 3. Uses patient-centered care techniques. initial questions were asked, soliciting 4. Uses communication skills that enhance the physician/patient relationship. their opinion regarding the impact of the 5. Facilitates lifestyle changes in patients. IFM program on their Match outcomes and process. All program directors 6. Knows how to refer appropriately to practitioners of complementary and alternative medicine (100%, n ϭ 6) indicated that there was a (CAM). positive impact on recruiting from the 7. Practices constructively and collaboratively with other health care team members. IFM program. Also, three of those asked 8. Assesses scientific and historical evidence for allopathic as well as CAM approaches to specific agreed the presence of the IFM program diseases and syndromes. brought in more desirable applicants, and five thought the program also brought in 9. Integrates mind-body recommendations into practice appropriately. more applicants. 10. Integrates botanical recommendations into practice appropriately. 11. Integrates nutrition recommendations into practice appropriately. Recognizing the subjective nature of these self-reported ratings, we also 12. Integrates physical activity recommendations into practice appropriately. collected rank lists and applicant ratings 13. Counsels and supports patients regarding spirituality. on stated level of interest and overall 14. Composes and administers individualized integrative medicine treatment plans. quality/desirability for all family medicine residency applicants from all 15. Positively influences their organization and/or environment (local, regional and/or national) participating programs. Applicants were with regard to integrative medicine (which might translate into consulting, teaching, advocacy). identified by the program directors as either “highly interested,” “moderately interested,” or “not interested” based on the applicants’ statements of interest The IFM Program’s Outcomes during the application, interview, or Implementation, Preliminary The family medicine residency matching processes. In addition, program Outcomes Data, and Impact environment. Preliminary outcomes directors could identify that they “did not Implementation evaluation of the IFM program began know” the interest of the applicant. with the first class’ residential retreat in Applicant quality/desirability was also The criteria and interview process for January 2004. Of the methods identified rated by the program directors (“high selecting residents to be trained in the in List 3, we have implemented all but the quality,” “moderate quality,” and “poor IFM program were individually online mini-portfolio and the patient quality”) and was based on an evaluation determined by the six participating family survey. While it is premature to assess all of application materials and interview medicine residency programs. All residents outcomes as well as their comparative of the specific behavioral competencies in had to be in good standing within their ranking among current year applicants. this population of residents, we report programs and all had to have completed below our initial findings on the impact the application process for the associate Of the “high quality” applicants (n ϭ of the IFM program on the family fellowship. One or two positions were 108), 27 (25%) were highly interested in medicine residency environment at each made available to each residency program. site and on the achievement of various the IFM program and an additional 15 Each program weighed the value of two competencies by the residents in the IFM (14%) were moderately interested, participants against the cost of providing program. compared to only six (5%) who two salaries for fourth-year residents; most expressed no interest. Conversely, among sites had more interested candidates than During the first residency recruiting the “low quality” applicants (n ϭ 19), IFM positions. season (2003– 04), all participating only two had a high interest in the IFM faculty anecdotally noted an increase in program, only two were moderately We applied to and received approval the level of interest in the IFM program interested, and five had no interest. from the ACGME’s Family Medicine RRC by interviewees. In addition, several Subsequent analysis using Kendall’s tau for pilot status. On February 16, 2004, we medical students acknowledged visiting and Spearman’s rho correlations were notified that “the RRC voted to all six participating residencies during confirmed the impact of the IFM encourage the participating programs to 2003– 04 in order to secure a position in program on the matching process (Table pursue the integration of Integrative an IFM program’s participating 1). Kendall’s Tau correlations were used Medicine into their residency programs.” It residency. By the 2004 – 05 residency to compare applicant ranking score and is worth noting that this is only the second recruiting season, we had implemented interest in IFM and applicant quality and time in the history of that RRC that our evaluation plan and established more interest. Spearman’s rho correlations approval for implementation of an formalized procedures to evaluate were used to compare actual ranking experimental program has been awarded. whether the IFM program would bring quartile (1– 4) and interest. 586 Academic Medicine, Vol. 81, No. 6 / June 2006

Integrative Medicine Individual item scores ranged from List 3 67% to 100%, with a mean item score of Competency Evaluation Strategies Used to Evaluate Fellows in the Integrative 90% (SD ϭ .096) and a median score Family Medicine Program, 2006 of 83%. The six IFM program residents Primary methods each questioned the patient about spirituality and spiritual practices as well University of Arizona measures as nutrition and diet, and five questioned • Focused self-care plan the patient about the use of botanicals • Abrams’ transformation survey and supplements, nonphysical aspects of the health history, and use of CAM or • Well-being self evaluation instrument alternative health care interventions. The • Belief statement self evaluation behavior missed by two of the residents was “encouraged questions about the • Patient survey chief complaint and other issues at the • OSCE I and II end of the encounter.” • Knowledge assessments (nutrition, botanicals, mind-body interventions, physical activity, spirituality) These findings are limited by the small • Integrative medicine knowledge-skills-attitudes self rating scale sample size and the lack of a comparative group of family medicine residents to • Patient case scenarios determine if this group of residents was • Referral network evaluation relatively more competent in these skills than peers who have not engaged in the • Research critique and review assessment IFM program. Several items point to • Alumni survey areas that require additional attention in Local residency measures either didactic or clinical IFM program experiences. Yet, these preliminary results • Direct clinical observation indicate that overall this initial class of • Treatment plan evaluation IFM program residents are competent in • Online mini-portfolio patient-centered communication skills and are able to consistently conduct an • Faculty/peer/rotation performance evaluations integrative health history and patient Secondary method assessment. • Knowledge assessments/examinations Obstacles and Challenges Chi square analysis also confirmed that Residents’ competencies. In February The greatest challenges for the IFM there was a significant difference among 2005, we conducted a one-station program have been time, finances, and the four quartiles on interest in IFM objective structured clinical examination the multiple locations. The residents felt (␹2 ϭ 20.62, p ϭ .05). Of those highly (OSCE) of all associate fellows, including that, especially during the second year of interested in IFM (n ϭ 39), 27 (69%) the initial class of six IFM residents to their training, that the time required for were ranked in the first two quartiles. evaluate their achievement of the online curriculum was beyond that And of those that were highly ranked competencies associated with the (1) use available in their work schedule. Several (quartile 1), 12 (30.8%) were highly of patient-centered care techniques, (2) program directors agreed to free the interested in IFM, compared to 5% who use of communication skills that enhance resident from other responsibilities for were not interested. the physician/patient relationship, and one half-day each week. However, this (3) ability to perform an integrative proved to be impossible during the more These data are limited in two respects. health history and patient assessment. rigorous ward months due to the impact First, many of the program directors Patient actors measured 25 behavioral on their colleagues. Time challenges rated the applicants retrospectively based items expected to be present following became less daunting for residents in the on interview notes and records review. completion of the first year of the IFM third year of training. Second, due to the retrospective nature of program (these items are also expected to the data collection process in the 2004 – be present for all associate fellows). These Many residents used elective time to 05 residency recruiting season, over 50% included (1) gave verbal/nonverbal positive “catch-up” on the online curriculum; in of the applicants’ interest in IFM was reinforcement, (2) used open-ended rather general this was not ideal as they missed “unknown.” Revisions have been made to than forced-choice questions, (3) said the opportunity to participate in the the data collection process to assure in some manner “Your problem is interactive online discussion while it was prospective data collection on these items significant and interfering with your life,” being moderated by a faculty member, an during the 2005– 06 recruiting season. and (4) made eye contact. important part of the associate fellowship Yet, these preliminary analyses point to a curriculum. If the online curriculum potential positive impact of the IFM on Total OSCE scores ranged from continues to serve as the primary the quality and quantity of family 80 –100%, with a mean score of 90% curricular delivery method for this medicine resident applicants. (SD ϭ .075) and a median score of 90%. program, we will have to find ways to Academic Medicine, Vol. 81, No. 6 / June 2006 587

Integrative Medicine weaves together family medicine training Table 1 with an integrative medicine curriculum Comparison of Applicant Quality, Interest in the Integrative Family Medicine to create a new model for postgraduate (IFM) Program, and Residency NRMP Ranking 2004 –2005* training of family physicians. Designed as Residency program Quality and Rank and Quartile rank an embodiment model, it encourages and no. residents interest interest and interest residents to gradually integrate all that they Beth Israel/Albert Einstein Ϫ.013 Ϫ.070 Ϫ.085 learn into their patient encounters. The College of Medicine; 48 project embraces characteristics of the New ......................................................................................................................................................................................................... Maine Medical Center; 51 .339‡ .229† .247† Model of Family Medicine outlined by the ......................................................................................................................................................................................................... Middlesex Hospital; 32 .190 .089 .049 report on the future of family medicine ......................................................................................................................................................................................................... mentioned earlier.17 It emphasizes University of Arizona; 30 .573‡ .443† .436† ......................................................................................................................................................................................................... ‡ relationships between patients and University of Wisconsin; 78 .104 .347 .379‡ ......................................................................................................................................................................................................... ‡ ‡ physicians, comprehensive care, and the Total IFM program; 239 .161 .291 .187‡ commitment to provide all of family * The data were gathered retrospectively by asking program directors to subjectively assess the overall quality of medicine’s services, now expanded to their applicants and the expressed interest of the applicant in the IFM program. NRMP match lists from each include evidence-based complementary residency devoid of specific applicant identifying data were provided to the evaluation researcher (MK). Kendalls T and Spearman Rho correlation statistics were used to determine the correlation between quality of the and alternative medicine practices. applicant (rated as high, moderate and low by program directors), interest in the IFM program (rated as high, moderate and low by program applicants) and quartile ranking score (1– 4 as determined by the actual Match Early results suggest the program leads to ranking score received by the applicant from the residency program faculty). Quality, interest and quartile enhanced interest in family medicine ranking were all found to be highly correlated within the total program and more closely associated in programs at Maine Medical School, the University of Arizona and the University of Wisconsin. amongst graduating medical students, † p Ͻ .05. thus offering a potential solution to the ‡ p Ͻ .001. reduced interest in this primary care specialty. The unique delivery method allow residents full participation during of Medicine’s costs for faculty time, challenges medical educators to consider their second year. A final time challenge annual retreats, and the evaluation of the which of their own curricular efforts has been prioritizing time for self-care; in program. If these funds become might best be moved to online learning. general, this has not been a valued part of unavailable, ongoing access to the The IFM program evaluation is designed postgraduate education. associate fellowship will have to be to assess the development of competency funded in another way. Expanding access in integrative medicine amongst family The financial challenge has also been of the IFM program to the associate significant. Because this pilot program medicine residents. This represents a first fellowship as this program moves beyond for the field of integrative medicine and is a was granted “experimental” accreditation the six pilot schools offers both by the RRC, the fourth year of residency critical part of obtaining ACGME significant challenge and opportunity for accreditation. Ultimately, the Integrative does not qualify for Medicare pass- innovation. through funds, which support residents’ Family Medicine program project goes salaries in the first three years of training. Mentored online distributed learning beyond developing competency in Full accreditation status through the programs such as the associate fellowship integrative medicine and has the potential ACGME’s RRC, the program’s ultimate may prove to be the ideal educational to enhance family medicine as a whole. goal, would solve this problem. In the system for residents whose clinical Dr. Maizes is executive director, Program in interim, each of the sites has addressed responsibilities often leave scheduled Integrative Medicine, University of Arizona, and salary support for the fourth year in its lectures poorly attended. Comprehensive, associate professor of clinical medicine and family own way. Strategies include the use of interactive learning can fit into the less medicine, College of Medicine and the College of faculty development grant funds for the busy times in residents’ schedules. In Public Health, University of Arizona, Tucson, Arizona. fourth year of residency training; the addition, distributed learning may Dr. Silverman is education director, Program in reconfiguration of a family medicine ultimately prove to be more cost-effective Integrative Medicine, University of Arizona, Tucson, Arizona. program from eight residents per year for and offer greater curricular consistency. three years to six residents per year for Dr. Lebensohn is program director, Family Practice four years— enabling the same amount of A final challenge is the multicenter nature Residency Program, University of Arizona, Tucson, funds to be used over a longer period; of this project. While the value to the Arizona. private foundation support; and use of pilot of diversity is clear, scheduling Dr. Koithan is coordinator of educational research the revenue generated by the clinical conference calls and retreats across time and evaluation, Program in Integrative Medicine, zones and faculty schedules is difficult. University of Arizona, Tucson, Arizona. work of the fourth-year residents to cover salary costs. The latter strategy potentially Evaluation is significantly affected as well; Dr. Kligler is research director, Continuum Center puts the educational experience of the consistency of data collection including for Health and Healing, and associate professor of timing, completeness, and interrater family medicine, Albert Einstein College of Medicine, resident at risk in favor of the pressure New York, New York. for productivity. reliability issues grow in complexity when carried out across the six sites. Dr. Rakel is director of integrative medicine, School of Medicine and Public Health, and assistant The second financial challenge is the need professor, Department of Family Medicine, University for continued support to underwrite the of Wisconsin, Madison, Wisconsin. costs of the associate fellowship program. Summing Up Dr. Schneider is director of integrative medicine, The U.S. Department of Education has The Integrative Family Medicine Department of Family Medicine, Maine Medical offset the University of Arizona College program is a unique pilot program which Center, Portland, Maine. 588 Academic Medicine, Vol. 81, No. 6 / June 2006

Integrative Medicine Dr. Kohatsu is assistant professor, Department of 4 Sibinga E, Ottolini MC, Duggan AK, Wilson 12 Kligler B, Gordon A, Stuart M, Sierpina V. Family Medicine, Oregon Health & Science University, MH. Parent-pediatrician communication Suggested curriculum guidelines on Portland, Oregon. about complementary and alternative complementary and alternative medicine: medicine use for children. Clin Pediatr. 2004; recommendations of the Society of Teachers Dr. Hayes is assistant professor of family medicine 43:367–73. of Family Medicine Group on Alternative and co-director of the Integrative Medicine Medicine. Fam Med. 2000;2:30–33. Fellowship, Family Medicine Department, Oregon 5 Corbin WL, Shapiro H. Physicians want Health & Science University, Portland, Oregon. education about complementary and 13 Complementary and Alternative Medicine in alternative medicine to enhance the United States: Institute of Medicine Dr. Weil is founder and director, Program in communication with their patients. Arch Report (January 12, 2005) (http://www. Integrative Medicine, and clinical professor of Intern Med. 2002;162:1176–81. iom.edu/CMS/3793/4829/24487.aspx). medicine and public health, University of Arizona, Accessed 7 March 2006. Tucson, Arizona 6 Suter E, Verhoef M, O’Beirne M. Assessment of the information needs and use of 14 Campos-Outcalt D, Senf J, Kutob R. A information resources on complementary comparison of primary care graduates from and alternative medicine by Alberta family schools with increasing production of family Disclaimer physicians. Clin Invest Med. 2004;27:312–15. physicians to those from schools with The contents of this paper were developed under 7 Derr S, Shaikh U, Rosen A, Guadagnino P. decreasing production. Fam Med. 2004;36: a grant from the U.S. Department of Education. Medical students’ attitudes toward, 260–64. However, those contents do not necessarily knowledge of, and experience with 15 Campos-Outcalt D, Senf J, Kutob R. represent the policy of the Department of complementary medicine therapies. Acad Comments heard by US medical students Education, and readers should not assume Med. 1998;73:1020. about family practice. Fam Med. 2003;35: endorsement by the federal government. 8 Wetzel MS, Kaptchuk TJ, Haramati A, 573–78. Eisenberg DM. Complementary and 16 Pugno P. Mixed Results Overall: Family alternative medical therapies: implications for Medicine Fill Rate Moves Upward in 2005 References medical education. Ann Intern Med 2003; Match. American Academy of Family 1 Maizes V, Horwitz R. Ethics, education and 138:191–96. Physicians (AAFP) News Now 2005 March 18. integrative medicine (http://www.ama-assn. 9 National Center for Complementary and 17 Martin JC, Avant RF, Bowman MA, et al. The org/ama/pub/category/13194.html). Accessed Alternative Medicine (http://nccam.nih.gov/). future of family medicine: a collaborative 7 March 2006. Ethics JAMA. 2004;6(11). Accessed 7 March 2006. project of the family medicine community. 2 Barnes PM, Powell-Griner E, McFann K, 10 Consortium of Academic Health Centers for Ann Fam Med. 2004;2 suppl 1:S3–S32. Nahin RL. Complementary and alternative Integrative Medicine (http://www. 18 Maizes V, Schneider C, Bell I, Weil A. medicine use among adults. United States, imconsortium.org). Accessed 7 March 2006. Integrative medical education: development 2002. Adv Data. 2004;343:1–19. 11 Kligler B, Maizes V, Schachter S, et al. and implementation of a comprehensive 3 Adler SR, Fosket JR. Disclosing Education Working Group, Consortium of curriculum at the University of Arizona. Acad complementary and alternative medicine use Academic Health Centers for Integrative Med. 2002;77:851–60. in the medical encounter: a qualitative study Medicine. Core competencies in integrative 19 Accreditation Council for Graduate Medical in women with breast cancer. J Fam Pract. medicine for medical school curricula: a Education (http://www.acgme.org/outcome/ 1999;48:453–58. proposal. Acad Med. 2004;79:521–31. comp/compFull.asp). Accessed 7 March 2006. Did You Know? A researcher at Stony Brook University School of Medicine, in 1973, developed an imaging technique for taking three- dimensional pictures of body organs and vessels without the use of ionized radiation or toxic dyes. This technique was used as the basis for the manufacture of MRI equipment. For other important milestones in medical knowledge and practice credited to academic medical centers, visit the “Discoveries and Innovations in Patient Care and Research Database” at (www.aamc.org/innovations). Academic Medicine, Vol. 81, No. 6 / June 2006 589

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