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Ann Behav Sci Med Educ. Author manuscript; available in PMC 2015 August 26. Published in final edited form as: Ann Behav Sci Med Educ. 2008 ; 14(2): 56–61.

Toward Interdisciplinary Care: Bridging the Divide between Biomedical and Alternative Health Care Providers William G. Elder Jr., Ph.D., University of Kentucky

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Deborah L. Crooks, Ph.D., University of Kentucky Samuel C. Matheny, M.D., M.P.H., and University of Kentucky Chester D. Jennings, M.D. University of Kentucky

Abstract

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Purpose—Responding to suggestions that physicians are obligated to inquire fully about complementary and alternative medicine (CAM) use and its scientific evidence, to acknowledge patients’ health beliefs and practices, and to accommodate diverse healing practices, our interdisciplinary CAM integration project created an advisory committee (AC) composed of CAM practitioners and institutional personnel to incorporate CAM- related information into health professions training. We report on the collaborative process and describe group members’ perceptions of medicine and clinical teaching. Methods—Information collected from the first two years’ quarterly meetings, the first annual retreat, and other venues was analyzed in conjunction with semi-structured in-person interviews of 10 biomedical and CAM practitioner committee members. Data were analyzed using qualitative methodology and N5 software to identify themes and patterns.

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Results—Analysis confirmed expectations that allopathic and CAM AC members held different views of health and healing. Member comments reflected points of tension that clustered into three intertwined themes: what constitutes evidence, interaction with the patient, and the relative importance of experience in learning. Recommendations for designing interdisciplinary CAM curricula are presented. Conclusion—Differences between CAM and allopathic providers were frequent but did not obviate common goals or collaboration. Results demonstrate the potential for collaboration between these groups and our activities may be useful to others seeking to implement interdisciplinary care, particularly between CAM and allopathic providers.

William G. Elder, Jr., Ph.D., University of Kentucky, College of Medicine, Lexington, KY 40502, [email protected].

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Keywords interdisciplinary teaching; attitudes of health personnel; medical pluralism; alternative medicine; curriculum development; group process; medical education; participant-observer

Background and Objectives

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Patient use of complementary and alternative medicine (CAM) is widespread and often utilized concurrent with conventional medicine.1 Collaboration between conventional health care professionals and CAM practitioners has been identified as critical for effective health care delivery.2 The Institute of Medicine2 suggests that, for reasons of patient safety and to promote positive patient relationships, physicians acknowledge that there are multiple valid modes of healing and that health care adopt a more pluralistic approach. Tilburt and Miller3 suggest that physicians are to acknowledge patients’ health beliefs and practices, and to accommodate diverse healing practices.

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Several researchers have described issues that arise when CAM and conventional practitioners attempt to collaborate. According to Barrett,4,5 CAM practitioners experience differences in philosophy and beliefs as barriers to collaboration. An absence of common language or lack of shared meaning may result in distinct divisions of labor; biomedical practitioners may focus on diagnosis and treatment of disease, while CAM practitioners concentrate on illness and quality of life.6 Although perhaps not always successful,7,8 academic health centers have sought, since the Flexner Report of 1910, to root curricula in the scientific method and the biomedical model.9 In contrast, beliefs held by CAM practitioners regarding the nature of evidence and explanatory models that ultimately guide evaluation and treatment often differ, perhaps even radically.10,11 Recognizing the need for more knowledge about CAM, the National Institutes of Health formed the National Center for Complementary and Alternative Medicine (NCCAM) to conduct research and inform health care professionals and the public about CAM. As part of their dissemination strategy, NCCAM created grant-based programming to incorporate CAM- related information into health professions training, and between 2000 and 2002, funded 14 medical and nursing schools and the American Medical Student Association (AMSA), to develop innovative CAM curricular initiatives for medicine, nursing, and other health professions trainees.12 AMSA in turn, funded six additional medical colleges13 for a total of 20 schools.

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A specific focus of one of the NCCAM-funded projects, the University of Kentucky, College of Medicine Interdisciplinary CAM Integration Project (ICIP), was to prepare health care professionals to work more collaboratively with CAM practitioners. The ICIP identified 19 courses appropriate for inclusion of CAM content; directors for 80% of those courses indicated that they viewed their individual level of knowledge about CAM as a barrier to its inclusion. The ICIP devised a strategy of having CAM practitioners serve as experts on content who could co-teach CAM elements with course directors. It was believed that CAM practitioners’ involvement in teaching would promote positive attitudes towards collaborative care by having students learn material directly from CAM practitioners as well

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as by seeing collaboration modeled by their instructors in the form of interdisciplinary curriculum development. In keeping with Flexner, a plan for an Evidence-Based Medicine (EBM) process was created to integrate CAM content and presenters into existing courses, wherein the ICIP worked with course directors and CAM practitioners to select and prepare CAM content, including being able to present information on efficacy and safety of CAM modalities.

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Among the NCCAM funded- projects, University of Kentucky’s model may have been unique in the extent to which it included community-based CAM practitioners alongside interdisciplinary institutional personnel.14 Differences in group members’ perceptions of medicine and strategies for teaching as they sought to shape a new curriculum are described here. We hope to illuminate these differences so that the unique perspectives of CAM practitioners may be better understood. In addition, the process of our Advisory Committee (AC) is described, to inform others seeking to conduct collaborative projects.

Methods

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Recognizing the difficulties of bringing together meaning systems and healing modalities that are fundamentally different, we formed an AC composed of 10 CAM practitioners and community representatives, 9 University of Kentucky representatives, and 2 medical student and resident representatives (see Table 1 for areas of expertise). The purpose of the AC was to advise the principal investigator (WGE) on the academic endeavor of CAM curriculum development, including identifying and developing standards for quality education, defining effectiveness and evaluating the curriculum, and reflecting on learning outcomes, quality and diversity of faculty, and process fairness. A medical anthropologist (DC) was engaged as a participant- observer to analyze group process and to report differences in perspective among group members.

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Institutional members of the AC were selected based on having various curriculum development roles in the project. CAM members were initially selected based on their prior work with the principal investigator or other faculty teaching about CAM (e.g., in an elective course). We sought to balance representation of multiple CAM modalities with the need to keep the group to a manageable size. Individuals representing additional modalities (e.g., acupuncture) were added at the recommendation of the initial group members. AC meetings were two hours in length and were held in the evening to accommodate CAM practitioners’ needs to be available to their practices during the day. CAM practitioners received an honorarium for each meeting. The AC meetings were led by the principal investigator who, in planning with the anthropologist, structured the meetings to facilitate collaborative problem solving by asking members to state their “interest” in being on the AC or the problem being discussed, encouraging sharing of perspectives and ideas, stating “problems to solve,” breaking the AC into small groups for discussion, providing time for reflection, and offering comments on process. Acting as a participant-observer, the medical anthropologist collected information from the first two years’ quarterly meetings, the first annual retreat, and other venues. These were analyzed in conjunction with semi-structured in-person interviews of 10 biomedical and

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CAM practitioner committee members. Handwritten notes of all meetings and three of the 10 interviews were expanded immediately after the encounter; the other seven interviews were tape recorded and transcribed. Data were entered into N5 (formerly Nud*ist), coded, and analyzed to identify themes and patterns.15,16 All procedures were approved by the non-medical Institutional Review Board. Our Dean of Evaluation, who was in charge of curriculum evaluation, and the principal investigator were not interviewed in collecting these data.

Results

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Analysis confirmed expectations that AC members held very different views of health and healing. In a few cases, epistemological differences were profound. For example, while some CAM members’ views were quite conventional in terms of accord with a biomedical model, others, particularly those whose modalities incorporated interventions with energy fields, held explanations far afield from Western medicine. Member comments reflected points of tension that clustered into three intertwined themes: what constitutes evidence, interaction with the patient, and the importance of experience in learning. These themes were fundamental in discussions and negotiations of curriculum content, outcomes, and teaching methods. Three intertwined integration themes

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Evidence: Explanatory models and what constitutes clinical evidence—CAM AC members felt that the scientific method (especially randomized controlled trials) is too limiting. They commented that evidence can differ by paradigm and participants. Some noted that their approaches were traditional, having been confirmed through thousands of years of use. They also indicated that the outcome of a modality may rest in the perceived results of the encounter and that validity should be examined in the context of expectations that are negotiated between patient and practitioner.

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As one CAM practitioner explained, “This is part of our challenge – to be aware of evidence and to present ideas and evidence such as case studies and the history of the modality. [With CAM practitioners] there may be an antipathy toward the need for [scientific] evidence, or maybe CAM practitioners don’t understand or value science. There is often a mistrust of science.” Concerns about evidence were not necessarily related to inexperience with the scientific model, but reflected some member’s sophisticated understandings of epistemological issues. One CAM AC member stated, “What we need to do is give students an understanding of what constitutes valid knowledge…give them the basis for understanding and help them understand that biomedicine and alternative medicine are not to be compared in the same way.” CAM AC members pointed out that, clinically, CAM modalities may assess or monitor different data. For example, some approaches might gather information on tongue condition, perceive patient changes in energy fields, or examine the pulse differently. They noted that healing was different from treatment, and that illness was different from disease. They pointed out that their modalities might facilitate the body’s own healing process rather than act as an external agent, and that their approaches were often directed to the whole person rather than an organ system or a symptom.

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Institutional AC members believed CAM and conventional therapies should be held to the same levels of scientifically based evidence, yet they also recognized the need to teach students that effectiveness can be demonstrated with innovative study designs. They also felt that students need to understand systems and philosophies that are “alternative” to the mainstream. Patient interactions—CAM AC members pointed out the importance of the clinicianclient interaction in outcomes. Some noted that the relationship, through empowerment, was in itself healing. Many perceived themselves as superior in patient- centered care and comments revealed assumptions that conventional practitioners did not understand relationally based care. They suggested that the project focus less on teaching CAM content and more on helping students understand the importance of valuing other people’s perspectives.

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Institutional AC members agreed with the importance of relationships in care and outcomes and that some CAM practitioners might have superior relational skills that could be advantageous for students to learn. They were concerned that teaching about the relationship might lead some students to over-attribute CAM outcomes to “relational influence” rather than efficacy of the modality.

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Importance of experience—CAM AC members believed it critical that students gain knowledge of their modality by personal, real-world experience rather than didactic teaching. For example, when planning a panel discussion of varying approaches to a health problem, CAM AC members advocated that, rather than case studies, an actual patient be present. They pointed out that case studies, no matter who wrote them, are artificial and omit information that CAM practitioners may respond to either directly or intuitively, consistent with their view of what constitutes evidence as described above. Regarding personal experience with the modality, CAM members thought such experience was vital to understanding the modality, “through experiencing its healing effects.” Institutional AC members agreed that conventional medicine omits important data giving the example that physicians have lost some of their observation skills. They believed observation of a CAM practitioner/patient encounter would be a valid learning experience. Process issues: clarity, communication and respect

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The AC met regularly during years one to four of the five-year project. However, the period of interest from which the data were presented here gathered is from the beginning of the project funding period until half way through the third year (21/2 years). At that point we stopped collecting this information using this methodology. Data indicate the purpose of the committee was not always clear to its members. However, this did not seem to hamper the work of the committee. In 10 interviews, not one committee member was able to articulate the role of the AC with respect to the greater project; however, all but one had a clear vision of their own role on the committee, and most spoke at length about issues that had been discussed and negotiated at the various meetings. CAM providers saw themselves as a “bridge” between alternative and biomedical paradigms and

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all were well engaged with the work of the committee (and most, enthusiastically). Thus, even if they were not always clear about its purpose, CAM practitioners were actively involved in the AC. For example, to examine the feasibility of having students see their own patients, CAM practitioners informally questioned their patients to ensure that they would be comfortable with students present. Most CAM members believed their opinions were welcomed and the meeting format allowed open communication, but some objected to “academic talk” involving overheads and bullet points. Many commented on historic distrust and perceived disrespect. One CAM member stated, “There still is the undercurrent of [feeling that] the alternative people are not as educated and they don’t know their stuff…” Uneven attendance by some institutional members was viewed as a lack of commitment. The location of meetings at UK evoked questions of power.

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CAM AC members initially expressed concern that the committee would “co-opt CAM practitioners” through an approach that would fail to “find value in teaching CAM models.” However, the CAM practitioners did not subsume their own perspective under the biomedical model to foster the goals of the project. For example, they continued to press for the importance of actual patient experience in the creation of curricular activities and identified learning objectives associated with direct patient contact.

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As stated, a project goal was to incorporate CAM content into the curriculum using Evidence-based medicine principles to select and deliver that content. Members reached a position that recognized the importance of conventional evidence in the academic culture. The AC considered questions as to which modalities to focus on first in curriculum development and decided on a strategy of selecting those CAM approaches with the strongest evidence of efficacy or potential danger for initial inclusion. Table 2 summarizes the AC’s curricular recommendations.

Discussion These results suggest that differences in philosophies of care and teaching between CAM and allopathic providers were frequent. Despite these differences, these two groups worked together to answer the questions, “What do we want medical students to know, and how do we want to do it?” This cooperation served to enhance curriculum development, particularly by producing learning objectives and activities.

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These themes present characteristics and tensions similar to those identified by other researchers. 13,14, 17 Using closed-and open-ended questions, Barrett and colleagues identified four themes as either characteristic of CAM or as marking a contrast of CAM with conventional medicine: holism, empowerment, access, and legitimacy. Our findings regarding themes of evidence and patient interaction largely duplicate Barrett’s holism and empowerment themes. Because we were not seeking through these discussions to build clinical collaboration, Barrett’s access and legitimacy issues did not develop as themes. They were, however, identifiable in group process. There were initial concerns about access in the form of voice in the curriculum. Legitimacy concerns took the form of concerns about

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co-option, which would have adopted what was useful without legitimizing the perspective of the CAM group. In the University of Kentucky case, this might have happened if the project had, for example, decided that the effectiveness of CAM modalities is principally found in the practioners’ interpersonal influence on the patients.

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CAM practitioners would not, as McGuire put it, 18 translate CAM into Western medical terms and were not prepared to subsume their own perspective under the biomedical model to foster the goals of the project. In fact, they were declaring that the goals would only be fostered by recognition and valuation of the epistemologies and practices of complementary and alternative modalities. Our experience affirmed Goldner’s observations of how formal organizations can be reshaped by CAM practitioners.12 Likening CAM to an activist movement united through ideology of shared meaning, Goldner found that CAM and conventional groups are in continual negotiation and that relationships are constantly evolving.

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That CAM AC members appeared to see themselves as more patient-centered than conventional practitioners was a barrier to mutual understanding and collaboration. They were unaware that training in patient- centered attitudes and skills was an existing part of curricula. At the third annual retreat, entitled “Finding Common Ground,” AC members were oriented to existing patient-centered care curricula, identified areas of agreement, and endorsed efforts to insert patient-centered attitudes and skills unique to CAM into the existing curricula. New student learning objectives created as an outcome of this process appear as 1 e and f in Table 2. These objectives sought to increase student understanding of the relational techniques unique to the CAM modality and to emphasize the value in the patient centered approach of exploring the patient’s perceptions of a treatment and its outcomes. While we believe we were successful in obtaining a collaborative process, our results may not be generalizable to all other settings as they are dependent on the group members in this context and the problems they were working on. Our results should serve to inform others about how a group structured this way, recognizing the needs and challenges of openness and pluralism, might work together. This information should be of value to programs and departments to inform them about CAM content and activities, including collaboration with CAM practitioners.

Conclusion

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While the themes serve to contrast the two groups, they are made apparent through discourse obtained as these two groups attempted to work together and find solutions. They should not be considered an endpoint but rather as a picture in time of the group members’ perceptions of each other’s clinical and teaching domains, as individuals and as groups. Their differences did not obviate common goals or collaboration and enriched the views of all concerned about what is unique about CAM and how it may be taught in a university medical center.

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Acknowledgment This project was supported by grant 5 R25 AT000682 from the National Institutes of Health, National Center for Complementary and Alternative Medicine (NCCAM). Submitted: August 8, 2008

References

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1. Eisenberg D, Davis R, Ettner S, Appel S, Wilkey S, Van Rompay M, Kessler R. Trends in alternative medicine use in the United States, 1990–1997: results of a follow-up national survey. JAMA. 1998; 280:1569–1575. [PubMed: 9820257] 2. Institute of Medicine. Complementary and Alternative Medicine in the United States. Washington, DC: National Academies Press; 2005. 3. Tilburt J, Miller F. Responding to medical pluralism in practice: a principled ethical approach. J Am Board Fam Med. 2007; 20:489–494. [PubMed: 17823467] 4. Barrett B, Marchand L, Scheder J, Plane MB, Maberry R, Appelbaum D, Rakel D, Rabago D. Themes of holism, empowerment, access, and legitimacy define complementary, alternative, and integrative medicine in relation to conventional biomedicine. J Altern Complement Med. 2003; 9:937–947. [PubMed: 14736364] 5. Barrett B, Marchand L, Scheder J, Appelbaum D, Plane MB, Blustein J, Maberry R, Capperino C. What complementary and alternative medicine practitioners say about health and health care. Ann Fam Med. 2004; 2:253–259. [PubMed: 15209203] 6. Shuval J, Nissim M, Smetannikov E. Entering the well-guarded fortress: Alternative practitioners in hospital settings. Social Science and Medicine. 2002; 55:1745–1755. [PubMed: 12383459] 7. Starfield B. New paradigms for quality in primary care. Brit J Gen Pract. 2001; 51:303–309. [PubMed: 11458485] 8. Curtis, P. Program on Integrative Medicine. University of North Carolina at Chapel Hill; 2004. Evidence-Based Medicine & Complementary and Alternative Therapies. 9. Beck A. The Flexner Report and the Standardization of American Medical Education. JAMA. 2004; 291:2139–2140. (Reprinted). [PubMed: 15126445] 10. Goldner M. The dynamic interplay between Western medicine and the complementary and alternative medicine movement: how activists perceive a range of responses from physicians and hospitals. Sociol Health Illn. 2004; 26:710–736. [PubMed: 15383038] 11. Anderson R. A case study in integrated medicine: Alternative theories and the language of biomedicine. Altern Complement Med. 1999; 5:165–173. 12. Haramati A, Elder W, Heitkemper M, Warber S. Insights from educational initiatives in complementary and alternative medicine. Academic Medicine. 2007; 82:919–920. 13. Lee MY, Benn R, Wimsatt L, Cornman J, Hedgecock J, Gerik S, Zeller J, Kreitzer MJ, Allweiss P, Finklestein C, Haramati A. Integrating complementary and alternative medicine instruction into health professions education: organizational and instructional strategies. Acad Med. 2007; 82:939– 945. [PubMed: 17895652] 14. Sierpina V. Progress notes: University of Kentucky. Alter Thera. 2003; 9:88–90. 15. LeCompte, M.; Schensul, J. Ethnographer’s Toolkit. Walnut Creek, CA: AltaMira Press; 1999. Analyzing and interpreting ethnographic data. 16. Emerson, R.; Fretz, R.; Shaw, L. Writing Ethnographic Fieldnotes. Chicago: University of Chicago Press; 1995. 17. Pizzorno J. CAM differentiated. MAQ. 2002; 16:405–407. 18. McGuire M. Not all alternatives are complementary. MAQ. 2002; 16:409–411.

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Table 1

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Composition of the advisory committee CAM Practitioners and Community Representatives Acupuncture

Ayurvedic Medicine, Transcendental Meditation

Chiropractic

Herbalism

Massage Therapy

Mind-body Approaches

Tai Chi

Osteopathy

Energy Healing

Integrative Medicine Physician

Holistic Nursing Institutional Members

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Senior Associate Dean for Medical Education

Assistant Dean - Student Assessment & Program Evaluation

Office of Integrative Studies

Liaison for the Community-Based Faculty Program

College of Health Sciences (Allied Health)

College of Medicine, Curricular Design

College of Nursing

Medical Student

Principal Investigator

Resident

Medical Anthropologist (Participant-Observer) Other Personnel Present Curriculum Consultant

Project Coordinator

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Table 2

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ICIP Curricular decisions based on AC findings 1)

In selecting content for course inclusion, first focus on modalities that have strongest levels of evidence or that may be most dangerous, followed by modalities that are frequently used in Kentucky.

2)

Modality related learning objectives to consider when integrating into most course activities: a.

Identify clinical goals of the CAM modality.

b.

Describe 3 treatments or techniques performed in the modality.

c.

Identify levels of evidence for the modality.

d.

Identify explanatory model inherent in the modality and practitioner’s view of how modality obtains desired results.

e.

Discuss any limitations inherent to the “western scientific model” in understanding the modality.

f.

Identify patient centered and relational techniques exemplified in the CAM modality.

g.

Identify patient’s perceptions of therapy and outcome.

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3)

Add CAM modalities to those treatments examined in EBM course to increase learners’ understanding of strengths and limits of scientific method and to increase awareness of evidence for some CAM modalities.

4)

Create activities to occur during UK Cultural Competency programs to engage critical thinking about alternative philosophies and systems.

5)

Identify and enhance opportunities for students to observe CAM modalities with actual patients.

6)

Identify and enhance opportunities for students to experience CAM modalities personally.

7)

CAM practitioner training:

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a.

Provide CAM practitioners training activities to increase their understanding of typical medical teaching, especially precepting, to enable practitioners to avoid to avoid being prceived as different solely on the basis of teaching style, and to prepare ioners to teach specific learning objectives.

b.

Involve experienced CAM practitioners in training of new practitioners to discuss teaching experience, including willingness of students having to have direct observation and contact with practitioners’ patients.

c.

Provide faculty development activities to increase CAM practitioner knowledge of conventional research, to increase valuing of conventional research and to enhance ability to interact with conventional researchers.

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Toward Interdisciplinary Care: Bridging the Divide between Biomedical and Alternative Health Care Providers.

Responding to suggestions that physicians are obligated to inquire fully about complementary and alternative medicine (CAM) use and its scientific evi...
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