This paper aims to remedy a gap in the knowledge by presenting the first critical review of the literature on major themes relating to medical students perceptions and attitudes towards the exponentially growing field of complementary and alternative medicine (CAM).
After a comprehensive database search of the literature, 21 papers were chosen as suitable for the review. The results from these papers were tabled and discussed.
The results indicated that medical students lacked knowledge of CAM and are generally positive towards CAM education (especially in the preclinical years, if it provided evidence of efficacy and post-placement). Medical students thought that CAM should generally be incorporated into the medical curriculum mainly so they can confidently undertake referral to CAM practitioners. Being able to communicate with future patients about their CAM use was a major motivation for medical students to learn about CAM and a factor for medical student support of further incorporation of CAM content in the medical curricula. Educational exposure to CAM in many forms and in many papers was shown to significantly affect medical student attitudes to CAM. This may be reflective of the fact that, outside direct CAM training, there may be limited accessible opportunities for medical students and if integration is to occur, educational exposure is most important.
The rise of CAM as a social and clinical phenomenon necessitates consideration of further inclusion of these topics in the medical curriculum, if future physicians are to be able to fully discharge their role as care providers in an increasingly medically pluralistic world. However, the inclusion of CAM needs to be done in an objective and critical manner, which is relevant to the learner.
Patient use of complementary and alternative medicine (CAM) practitioners – a wide range of practitioners (e. g. acupuncturists, chiropractors, naturopaths and traditional medical system practitioners) and products (e. g. herbal medicines, nutritional supplements and homeopathy) which traditionally exist outside the conventional biomedical setting – has been exponentially increasing internationally over the previous decades [1, 2]. In some areas, CAM practitioner visits are now similar in numbers to visits and use of conventional medical approaches, and CAM practitioners’ numbers are similar to conventional physician numbers . In addition to increasing levels of patient utilization, CAM is being increasingly integrated into healthcare systems and, in some countries (such as China), is already highly integrated into healthcare . Philosophical divergence of conventional and CAM approaches to health has often resulted in significant professional tensions between CAM and biomedical practitioners, with significant and high-profile opposition to CAM use and integration in parts of the biomedical community [5–7].
Given findings that most people use CAM and conventional approaches concurrently , competition and resultant lack of collaboration between CAM and biomedical practitioners may be an incongruous situation that could ultimately be detrimental to patient/practitioner relationships. There is also general consensus that even if biomedical practitioners choose not to incorporate CAM practices, biomedical practitioners need to comprehensively understand other systems of healthcare that exist in their communities, basic information as to what these other health systems entail, and that they are very likely to encounter patients and practitioners who use them. As such, medical education accreditation bodies have endeavored to promote implementation of CAM content into medical curriculums to keep pace with community CAM activity and to bridge the gap between patients’ CAM and biomedical care [8, 9]. These efforts appear to have been productive, with US data indicating that in 2008, 90 % of US medical schools had CAM familiarization courses in their curriculum .
Stated reasons for the inclusion of CAM familiarization courses into medical curricula include the discussed exponential rise in CAM use amongst patients; poor, minimal or no medical student knowledge of CAM and confusion as to appropriate referral practices and subsequent poor CAM referral skills, medical student interest and curiosity in learning CAM (especially in the preclinical years of medical school) and to decrease possible communication deficits around their future mainstream medicine patient’s CAM use [8, 10–25]. However, the time allotted to CAM content in medical schools varies considerably. While medical education CAM content in Australia , Hong Kong  and the United Kingdom  appears to be minimal (with less than 5 h over an entire medical degree), in other countries such as Brazil  and South Korea , CAM content may be far more substantial and may even incorporate practical integration of CAM therapies .
However, despite the increasingly acknowledged need to develop CAM curriculum content in medical courses, and the apparent ad-hoc and variable manner in which this appears to be currently delivered, there has been little formal examination of this topic in the peer-reviewed literature of how different approaches to incorporation are perceived by medical students. The purpose of this paper is to remedy this gap and provide a guide for the medical education community by presenting the first critical review of the literature on major themes relating to medical students perceptions and attitudes towards CAM. Through systematic examination of this important issue, this paper provides the first review and synthesis of empirical research findings relating to medical student perceptions of CAM education and highlights a number of gaps and challenges facing future research in this area.
A comprehensive search of the literature in MEDLINE, CINAHL, AMED and PSYCINFO databases was conducted to obtain the major peer-reviewed literature on attitudes and perceptions of medical students to CAM. All databases were searched from their inception to January 2015. Databases were searched using standard terms and subject headings for complementary medicine, alternative medicine and integrative medicine, as well as terms for specific CAM disciplines (e. g. Chinese medicine, naturopathy, homoeopathy, acupuncture and chiropractic) and terms for specific CAM products (e. g. herbal medicine, supplements and vitamins). Appropriate terms and subject headings for medical education and medical students were also included. The search was confined to articles that were published in English.
One author conducted the search and downloaded the files into bibliographic management software (Endnote). Two authors independently examined the title and abstract of each result to identify relevant studies for inclusion. Papers that reported empirical research findings on medical student attitudes and perceptions towards CAM were selected. Studies not specifically focusing on this issue were also included if they provided empirical data on medical student attitudes and perceptions towards CAM. Any disagreement between authors regarding inclusion/exclusion was resolved by discussion. In situations where the abstract did not provide sufficient information, the full article was retrieved and examined before a decision was made. Database searches were supplemented by hand searches and all reference lists of papers reviewed for further references.
The search identified 917 articles using these search criteria. Of these, 815 were excluded as ineligible and abstracts and full-texts of the remaining 102 were read to compile a critical review to present, synthesize and analyze existing literature  on medical students’ attitudes and perceptions of CAM and CAM education. Twenty-one articles met the selection criteria to be included in the final review. Figure 1 summarizes the search strategy employed in this review, while Table 1 summarizes search terms used. The results are examined in terms of three broad areas: perceptions, attitudes and knowledge of medical students around CAM and CAM training; factors influencing medical student attitudes and perceptions around CAM and perceived impact of CAM training on future medical practice.
|Complementary medicine||Medical student education|
|Broad descriptor headingsa|
|Complementary medicine, traditional medicine, alternative medicine, integrative medicine||Medical student, medical education, teaching, curriculum, undergraduate medical education|
|Discipline- or modality-specific|
|Acupuncture, Alexander technique, aromatherapy, Chinese medicine, chiropractic, dietary supplements, herbal medicine, homeopathy, massage, meditation, naturopathy, nutraceuticals, reflexology, spiritual healing, vitamins, yoga|
The context and findings of the 21 papers were extracted, grouped and summarized using an integrative review approach . Papers were examined in relation to three main variables: perceptions, attitudes, and knowledge pertaining to CAM, the factors that shaped attitudes and perceptions, and the perceived impact of CAM training on future medical practice.
Based on this examination, ten major themes emerged from the papers. These are (1) medical students are generally interested in learning more about CAM; (2) among students in healthcare, medical students are those who currently have the least knowledge of CAM; (3) there is heterogeneity in interest in different modalities of CAM; (4) religiosity of medical students affects their interest in learning about CAM; (5) communicating with future patients about CAM use is a major motivation for medical students to learn about CAM; (6) medical students perceive a current lack of ability to refer future patients to CAM practitioners due to lack of knowledge of CAM; (7) the holistic principles of CAM are attractive to medical students and act as a motivator for medical students to understand CAM; (8) the attitudes of medical students change dramatically after exposure to CAM; (9) interest in CAM among medical students declines after the preclinical years of medical school (i. e. once medical students enter clinical component of their course); (10) evidence base is viewed as an important prerequisite of presented information in CAM familiarization classes. These individual themes are linked to individual articles in Table 2. The variables are discussed in detail below.
|Year||Country||Authors||Research focus||Method||Sample size||Main findings||Main themes discussed|
|1994||United Kingdom||Perkin et al. ||Comparison of attitudes to CAM of GP’s, hospital doctors and biomedical students||Survey||n=437||Medical students were the least informed but most enthusiastic respondents. The majority of respondents felt that alternative medicine should be available on the NHS and that medical students should receive some tuition about alternative therapies||1, 2, 9|
|1999||Norway||Syverstad et al. ||Measurement of changes of perceptions of biomedical students to CAM through the processes of medical school||Survey||n=421||After four more years in medical school, many more medical students would not use acupuncture if they had a condition that, in a traditional sense, acupuncture could treat. Changes in perceptions from the initial study to the follow-up study were significant in a negative direction||9, 10|
|2000||United Kingdom||Greenfield et al. ||Pre- and post-CAM education questionnaire of medical student attitudes to a study module in CAM||Survey||n=20||Pre-exposure there was a range of views towards CAM ranging from skepticism to acceptance though students saw the CAM exposure as a positive experience. Twelve of the students considered practicing CAM, most commonly acupuncture||3, 10|
|2003||United Kingdom||Furnham and McGill ||Medical students attitudes to CAM||Survey||n=311||Third-year medical students thought CAM was less effective than first-year students and were also less interested in studying CAM therapies||4, 6, 7, 8, 9|
|2005||Singapore||Yeo et al. ||Medical students knowledge, attitudes and perceptions of CAM||Survey||n=555||Medical students were most knowledgeable about acupuncture as a CAM therapy and no medical students were knowledgeable about chiropractic, osteopathy, Ayurvedic medicine, homeopathy and naturopathy. A large number of students had incorrect knowledge about CAM and they considered scientific evidence the main barrier to the integration of CAM with mainstream medicine. Overall medical students’ attitudes to CAM were very positive||1, 2, 3, 4, 5, 9, 10|
|2005||China||Hon et al. ||Medical student towards CAM (Traditional Chinese Medicine – TCM)||Survey||n=780||“Effectiveness of CAM”, “fewer side effects than Western medicine”, “illness not completely treated by Western medicine” and “recommendation from family and friends” were common perceptions of these medical students to CAM (TCM in this instance) that led many of them (33 %) to use CAM in the past year||2, 9, 10|
|2006||China||Wong et al. ||Medical student attitudes to TCM||Focus group interviews||n=28||This study explored medical student attitudes of TCM and its impact on future medical training. Lack of modern scientific evidence and no regulation were major barriers but the students thought understanding was of importance for future patient practitioner communication. They also thought that the future of medical education needed to change to integrate such practices||5, 7, 10|
|2006||USA||Torkelson et al. ||Pre and post CAM education intervention evaluation of a CAM rotation in a medical school||Survey||n=24||The post-CAM exposure results indicated that medical student confidence in CAM increased substantially. Also, the positive pre-course perceptions were maintained or increased and general perceived effectiveness of CAM increased post exposure||1, 8, 10|
|2007||USA||Ranjana et al. ||Medical student attitudes to CAM in the curriculum and in practice||Survey||n=266||91 % of medical students surveyed thought “CAM includes ideas and methods from which Western medicine could benefit”. 85 % of medical students thought “knowledge about CAM is important to me as a clinician” and 75 % thought CAM should be included in the medical curriculum||1, 10|
|2007||USA/China||Mao et al. ||Medical students attitudes and perception of CAM after an international CAM elective||Focus group interviews||n=80||Results showed that an international placement in acupuncture made medical students more open to other traditional health systems||9|
|2008||Israel||Shani-Gershoni et al. ||Measuring knowledge and attitudes of internists compared to medical students regarding acupuncture||Survey||n=122||With no differences between the variables of the sample, this study showed the following; that 93.4 % had never received training in acupuncture and that 84.4 % had never undergone acupuncture. The medical student’s level of CAM knowledge was extremely low. Despite this the participants believed acupuncture was more than placebo and that it would be beneficial to include acupuncture in the medical curricula||3, 7|
|2009||USA||Hoellien et al. ||Evaluation of CAM knowledge and clinical skills after CAM exposure||Analysis of formal assessment results||n=92||After a 4-h CAM exposure, workshop attendees performed significantly better on varied CAM testing||5|
|2010||Switzerland||Nicolao et al. ||Medical dean and faculty perception and opinions on how CAM should be taught to medical students||Survey||n=775||72.6 % of medical students are positive towards CAM education especially acupuncture, phytotherapy and homeopathy. The most popular ways that medical students and experts would like CAM education to be provided was through electives in the clinical years in the form of lectures and seminars||1, 3, 5|
|2010||United Kingdom||Donald et al. ||Medical student attitudes to CAM, before and after a short CAM (acupuncture) placement||Survey||n=40||There was a significant drop in skepticism of CAM of medical student’s post-placement. 90 % of students observed or performed acupuncture and 76 % of students who participated said that the placement would definitely affect the rate of their future referrals to CAM practitioners||5, 6, 8, 10|
|2010||Brazil||Amedera et al. ||Medical student attitudes after CAM study (in acupuncture)||Survey||n=25||98 % of medical students who concluded the course replied that the course was good or very good, 85 % considered themselves at least partially able to perform acupuncture and 79 % stated that the course influenced them in their medical education||1, 6, 8|
|2011||Austria, Germany and Switzerland||Brinkhaus et al. ||Analysis of integration of CAM into medical school curriculum||Survey||n=1,017||40 % of medical students had positive perceptions of CAM, 28 % were neutral, 29 % had negative opinions and 3 % were unsure. The most popular CAM modalities were acupuncture, osteopathy and naturopathy. The majority of respondents favored the integration of CAM into the medical curriculum but only 34 % stated that CAM had already been integrated into their teaching||3|
|2012||South Korea||Kim et al. ||Analysis of CAM content in the undergraduate medical curriculum||Survey||n=41||CAM was taught in 85 % of medical schools and 91.4 % provided credit for these courses. The most common courses included in respective order, introduction to CAM or integrative medicine, traditional Korean medicine, homeopathy, naturopathy and acupuncture. The most common format was lectures. The reasons why CAM was not taught include not enough time, a perceived lack of evidence base of CAM and unreliable CAM references||1, 6, 10|
|2012||USA||Anderson et al. ||Student assessment of a CAM/biomedicine exchange program in Chinese medicine||Survey||n=37||In this program, it was found that the medical students who took part found it highly valuable and a unique learning experience. The medical students stated that the main reason it was a positive experience was that it gave them a significant amount of referral information||6, 10|
|2012||Turkey||Akan et al. ||Medical student knowledge and attitudes of medical students towards CAM||Survey||n=943||The most well-known modalities that appeared in the results from the medical student surveys were, in respective order, herbal treatment (81.2 %), acupuncture (80.8 %), hypnosis (78.8 %), body based practices (77 %) and meditation (65.2 %). First-year students and females had the most positive perceptions of the different groups involved. Willingness to attend CAM training and positive attitudes towards CAM dropped as the number of years studying medicine increased||1, 2, 3, 9, 10|
|2013||Brazil||Guerreiro de Silva ||Analysis of CAM content (specifically acupuncture) in the medical curriculum||Survey||n=128||Using the survey scale, it was found that medical students would like more information, CAM study time was inadequate and acupuncture is an important part of the medical curriculum||1, 6, 8, 10|
|2013||Ireland||Loh et al. ||Medical student knowledge, perceptions and interest in CAM||Survey||n=1,585||78.4 % of medical students thought that knowledge of CAM is important for their future as medical professionals (low response rate – 20.1 %), 65 % stated they had not received adequate knowledge of CAM at medical school and 52.2 % of medical students thought CAM should be integrated into the medical curriculum. 49.4 % of medical students thought CAM should be taught in the preclinical years. Knowledge of CAM was rated as minimal or none by these students. There was a positive correlation between students who believed in religion and acceptance of CAM. Massage, spirituality and acupuncture were most popular CAM modalities. Clinical students were generally less interested in using CAM||1, 3, 4, 9|
|Australia||Templeman et al. ||Medical student attitudes and perceptions on need for CAM education||Qualitative interviews||n=30||Medical students generally held favorable attitudes towards CAM but had knowledge deficits. Medical students did not feel adept at counseling patients about CAM. All students were supportive of CAM education in medical education, mostly due to its importance in relation to the doctor–patient encounter and interactions with medical management||1, 2, 5|
Medical students’ attitudes, perceptions and attitudes towards CAM
Most studies of medical student perceptions showed that medical students thought increased CAM knowledge was of importance for their future as physicians [22, 29], wanted to advise and refer patients (and in some cases personally provide the CAM services as formally qualified medical personnel) [25, 30], felt that CAM had not been covered adequately in their curriculum (and therefore wanted CAM content introduced or expanded) [10, 16, 20–25] and, as a student body, felt that they had too little consultation with CAM practitioners compared with other health students. Although variability existed, medical students also had generally positive student attitudes towards CAM and its effectiveness [15, 29], thought being able to discuss their future patients CAM use could enhance patient/physician communication [16, 18, 21, 29], desired the opportunity to formally learn and create their own opinions of different CAM modalities , wanted to receive a basic knowledge of the most frequently and most important CAM modalities [16, 29]. Medical students also believed that CAM should be studied by biomedical practitioners before integration with modern medicine could occur . Among students of healthcare, medical students had the least knowledge of CAM, with comparative studies of medical students versus nursing and pharmacy students showing higher levels of CAM knowledge amongst these non-medical health student groups [15, 23, 25, 31].
The popularity of CAM modalities among medical students (in relation to the importance that they be considered in the medical curriculum) varied between regions (e. g. traditional Chinese medicine being more popular in Asia and homeopathy being more popular in Europe). Acupuncture was particularly identified as important for future inclusion in the medical curriculum, being the most or second most popular CAM modality for inclusion in seven of the medical student surveys [15, 16, 32–34]. Other individual CAM modalities or disciplines that were seen as important for inclusion were herbal treatments [15, 16, 22, 23], homeopathy [16, 32], massage , traditional Chinese medicine , hypnosis , chiropractic and nutritional supplements. Spirituality and prayer were also indicated to be one of the more popular CAM modalities measured, though this modality was excluded from most studies .
There was a high preference for evidence base as a prerequisite to inform CAM inclusion in medical curriculum, with 18 papers highlighting this strong preference among medical students, clinicians and faculty [10, 12, 13, 15, 19, 20, 23, 24, 30–32, 35]. This preference was not absolute, with 41 % of Singaporean medical students also suggesting that they would accept CAM based on long-standing traditions (such as TCM), even if it had not been tested in a scientific way . However, while evidence base and quality of CAM practitioner education were identified by medical students as important considerations for determining what CAM should be taught in the medical curriculum, and how they should interact with CAM practitioners in clinical practice, standards that were perceived as ‘too high’ could in fact adversely affect the support for CAM among medical students. For example, focus group interviews with Hong Kong biomedicine students found that biomedical students perceived that traditional Chinese medicine practitioners posed a threat to their future, as the training of TCM practitioners at their university was thought to be equal to or superior to the level of biomedical training .
Factors influencing medical student attitudes, perceptions and knowledge of CAM
A variety of factors may influence the perceptions and attitudes towards CAM and its place in the medical curriculum. A study of Turkish medical students highlights the heterogeneity of factors that influence CAM perceptions in the medical curriculum. In this study, the reasons offered by students as to why CAM should be incorporated in the medical curriculum included the following: there was a strong student interest in CAM, some students thought CAMs had therapeutic value, some students had family members who used CAM, students acknowledged weaknesses in the biomedical model and believed that other models should therefore be explored, students thought their future patients had the ability to choose between conventional medicine and CAM and therefore medical practitioners were obligated to learn about CAM and some students believed that spiritual experiences affected wellbeing and that these were acknowledged more by CAM than by conventional medicine .
One of the key factors influencing medical student attitudes and perceptions of CAM was exposure to CAM-specific training in their medical curriculum, with educational exposure to CAM generally correlated with an increased perceived usefulness of CAM. A 3-week CAM rotation in a US medical school, for example, saw medical student’s knowledge and subsequent willingness, in the future, to integrate CAM and to refer to CAM practitioners grow 16-fold, as well as significant increases in perceived CAM efficacy . A study of an acupuncture rotation by British medical students also resulted in three-quarters of respondents perceiving their placement would “definitely” increase their referrals to CAM practitioners in the future . A Brazilian study of acupuncture in the medical curriculum also saw that the perceived effectiveness of CAM increases substantially among medical students’ post-placement or education . After only a 6-h introduction to acupuncture in a Brazilian medical school, medical students felt it necessary to incorporate it formally in the medical curriculum, as the introduction was not felt to be adequate and simply increased medical students’ desire for further CAM information . CAM education may simply make medical students aware of the evidence base of some CAM therapies, and this itself may result in changed attitudes and perception: CAM therapies studied in the medical curriculum improve medical students’ recognized efficacy of CAM (where evidence exists) while the evidence was not recognized for those CAM therapies that were not included in the medical curriculum .
The holistic principles of CAM were also seen as a motivator for medical students to further explore and understand CAM. In one study of medical students in the United Kingdom, 77 % of students agreed with the statement that CAM was more holistic than (conventional) biomedicine, and there was high level of agreement that this holistic underpinning was the main reason for the success of CAM – both in relation to clinical treatment and public support . In some instances, medical students not only saw positive applications of incorporating holistic CAM principles, but also saw the potential threat to biomedicine through non-incorporation of these principles. A focus group study of Hong Kong biomedical student perceptions of traditional Chinese medicine highlighted that they saw a potential threat to biomedicine from traditional Chinese medicine as treating the whole person as a diagnostic principle in TCM was perceived by biomedical students as being superior to the perceived reductionism of the diagnostic principles of biomedicine .
One interesting factor that appeared to influence medical students’ perceptions and attitudes towards CAM in the medical curriculum was the religiosity of individual medical students. This was found to be both a negative and positive association, with an Irish study showing that if a student had no self-reported religion, they had a significantly lower interest in learning about CAM  and a survey of British medical students indicated that students who rated themselves as more religious were more likely to support increased CAM content in the medical school curriculum . An additional study showed that 57 % of medical students agreed that religious, personal or spiritual faith inspired them to trust CAM therapies .
Perceived impact of CAM training on future clinical practice
Medical students believed that patients should inform their doctors of CAM use  but acknowledged that as current knowledge deficits are causing doctors to be so hindered by their inadequate instruction in CAM, medical graduates are limited in their ability to, in any way, wisely help with patient autonomy in CAM use . Medical students also thought that incorporation of CAM into the medical curriculum could lead to better communication, stronger relationships and collaborations between biomedical and CAM practitioners, subsequently fostering potential improvements in patient care [12, 29]. However, without adequate knowledge and legal guidelines around CAM, it was perceived that as doctors, medical students would choose to avoid referring to CAM practitioners [10, 12, 17, 19–21].
Interest in CAM appears to decline after the preclinical years of medical school. This may relate to poor knowledge of medical students of CAM, with an Irish study showing low confidence associated with low knowledge levels resulting in clinical medical students being hesitant to discuss, use or refer to CAM with their patients . Peer pressure may also be a factor in this decline: with a Norwegian study exploring the impact of role models on CAM perceptions and attitudes suggesting that medical students want to “look like, be like and behave like” most other senior doctors, and these role models have been found to definitely be more skeptical of CAM than the students . Final year medical students in Turkey believed CAM was only able to treat simple disease, was unscientific, obscure and ambiguous and believed that CAM treatments were actually harmful to patients, contrasting with first year medical students in the same study, who thought many modalities of CAM were effective, demonstrated a desire to receive further training and perceived that they would actively recommend them to their future patients . A longitudinal survey of medical students in the United Kingdom found that all measurements regarding current knowledge, effectiveness and future training in CAM decreased between first and third year of medical school, and the same occurred for preparedness to refer to CAM practitioners. While first-year students in this study were generally positive about the role of CAM in healthcare, third-year students thought CAM had a low status within the health system and 84 % of third-year students in the study stated there were many “quacks” in CAM .
This article provides the first comprehensive exploration of medical student attitudes and perceptions to CAM. Findings from this article suggest that medical students are interested in learning CAM and often see it as important and highly relevant to their broader medical education and their future care of patients after graduation. Medical students appear to be aware that there is a growing public interest in, and public demand for, CAM, and as such, students perceive that they should reflect on this phenomenon from clinical, social and legal perspectives.
In contrast to the high level of interest of medical students to engage with CAM in their medical curricula, there appears to be little integration of CAM into medical curricula. As such, medical students appear to have lower levels of knowledge of CAM than other providers. This differential may be the result of many factors including faculty opposition budgetary and time constraints or lack of teaching staff with the appropriate expertise required to formulate appropriate and well-encompassed course materials. High-profile opposition to inclusion of CAM content in medical education settings , whilst not necessarily reflective of student or physician opinion, may make some medical schools hesitant to delve into what is perceived as a controversial area. However, to date, there has been no formal examination of medical curricula across regions or institutions to see if the medical CAM curricula appropriately reflect community use, whilst ensuring critical application.
The finding that medical student interest in CAM declines after the preclinical years of medical school is an unusual phenomenon that warrants further examination and suggests different educational interventions may be necessary at different stages of the medical curriculum. This could be the result of the professional tensions between CAM and biomedicine, which may become more overt once students begin clinical practice, but could also have other underlying reasons that warrant further examination. Previous studies suggest that positive clinical experience with CAM is one of the most predictive factors of physician support for CAM . It is possible that medical students in their clinical years have not been in practice long enough to observe such positive experiences. It is equally possible that medical students in their clinical years are for the first time influenced by negative or ineffective use of CAM. The impact of the perceptions and attitudes of clinical peers, or prioritization of newly applied conventional techniques by medical students, may also affect CAM interest.
The effects of medical education itself, and the critical skills this infers, in particular warrant further examination. The medical education focused on didactic, evidence-based, logical and rational deductive reasoning may not be perceived as entirely congruent with the paradigm of CAM , and this could influence medical student opinion. Developing an understanding of the prism through which students critically appraise CAM at different stages of their medical education is essential to ensuring that CAM education is appropriate and relevant.
The effects of religiosity of medical students and the draw of spirituality with respect to medical student attitudes and perceptions towards learning CAM warrant further exploration. Spirituality and religiosity have been associated with increased CAM utilization among the general public , and this phenomenon among medical students may simply reflect similar social trends as is observed in the broader population. The impact of prayer, suggested in some surveys – including those of medical students – to be among the most popular CAM, may confound these results.
Being able to communicate with future patients about their CAM was a major motivation for medical students to learn about CAM and a factor for medical student support of further incorporation of CAM content in the medical curricula. This reflects research in this area which highlights deficiencies in CAM–conventional communication between physicians and patients and improvements in care that may result from improved communication . It is clear the CAM community (both CAM users and CAM practitioners) and the medical profession need to understand each other and the best place to create this is to provide continual and adequate CAM training to medical students at university level. Some commentators highlighted, in regard to patient/practitioner relationships, they could even be held accountable as doctors for not recommending or informing a patient about a safer and equally efficacious CAM therapy and as such, lack of knowledge around CAM could be detrimental to clinical practice . Also, as patients rarely inform their doctors of their CAM use , the increase in knowledge and skills gained from learning about CAM could well further enhance the patient/practitioner relationship and may change the attitudes of medical students towards the field of CAM.
Educational exposure to CAM in many forms and in many papers was shown to significantly affect medical student attitudes to CAM. This may be reflective of the fact that, outside direct CAM training, there may be limited accessible opportunities for medical students. Evidence of CAM interventions was seen as the most important inclusion in CAM familiarization courses, but biomedical journals may not cover clinically relevant aspects of CAM such as effectiveness and efficacy, focusing instead on issues of safety and risk . Media (medical and lay) coverage of CAM may present results more negatively than they would for conventional medicine  meaning that students would need to venture further into the peer-reviewed literature for information, which may be beyond their scope of training or difficult to access. As such, the medical school environment may provide one of the few opportunities medical students will have to access CAM information that is critical, objective and trusted.
The rise of CAM as a social and clinical phenomenon necessitates consideration of further inclusion of these topics in the medical curriculum, if future physicians are to be able to fully discharge their role as primary care providers in an increasingly medically pluralistic world. However, there are important considerations for medical educators in relation to CAM inclusion in medical curriculums, which need to carefully balance evidence-based principles with the holistic paradigms that make CAM attractive to many patients and practitioners. Inclusion of CAM needs to be done in an objective and critical manner, which is relevant to the learner. However, despite CAM forming an increasingly significant part of the contemporary healthcare sector in many developed countries, there is little research on which to base a truly evidence-based approach to CAM inclusion in medical curriculums, and any inclusion appears to be done in an ad-hoc and sometimes informal manners. Further research of differing CAM inclusion approaches and their impact on learning and patient care outcomes is needed. Curriculum planners should consider the importance of evaluating the impact of CAM inclusion in medial curriculums to better inform medical education planning, policy and implementation.
All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission.
Research funding: None declared.
Employment or leadership: None declared.
Honorarium: None declared.
Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis and interpretation of data; in the writing of the report or in the decision to submit the report for publication.
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