Integrative medicine in the classroom

Georgetown’s evolving study in complementary and alternative therapies

 

Fifteen years ago, Georgetown began an effort to bring a new conversation into the medical school classroom. The newly established National Center for Complementary and Alternative Medicine at the National Institutes of Health awarded Georgetown’s School of Medicine a grant to integrate the study of nonconventional therapies into the four-year curriculum. Students would learn about what many of their patients were already using—complementary and alternative medicine (CAM) including acupuncture, herbal therapies, chiropractic treatments and mind-body medicine.

PATIENTS SEEKING KNOWLEDGE

In 1997, to connect with the community as an educational resource, Georgetown’s School of Medicine began offering an eight-week series of mini-medical school classes to the lay public. The science and medicine courses covered everything from what is molecular biology to why cells go bad, and the program was a hit. After that first session, organizers, including physiology and medicine professor Adi Haramati, Ph.D., sought customer feedback.

“When the course ended, we asked people, ‘What do you want next semester? An eightpart series on cancer? On neuroscience? On cardiovascular?’” recalls Haramati. The results? “Number one: nutrition. Number two: alternative medicine.”

He pauses. “What did I do with that? I ignored it. I didn’t think they were serious topics.”

At the end of the second semester of classes, they again surveyed participants. And again the results were the same. After the third round of classes and repeated feedback, despite his own bench-science skepticism, Haramati felt compelled to understand why nutrition and alternative medicine interested so many people. He began looking into the field.

At the same time, he was approached by Georgetown scientist Hakima Amri, Ph.D., who was researching the effects of plant extracts, and her colleague Vassili Papadopoulos, Ph.D. The two asked Haramati about using the mini-med infrastructure for a special series in complementary medicine. Their timing could not have been better.

Until this point, academic medicine had mostly ignored the fact that one third of Americans were using complementary medicine, and that many more were curious. The patients and the public drove the university to take a deeper look. In 1999, Georgetown’s first session on CAM was offered through the mini-medical school format.

The successful program generated new questions for Georgetown faculty. Seminar attendees revealed their thirst for more information on nonconventional medicine, but also a reluctance to discuss CAM usage with their physicians. This disconnect between patient and care provider prompted Georgetown faculty to ask why the gap existed and consider ways to bridge the gap. They realized that future physicians would need to be better versed in the field, and one way to address the problem was to better prepare Georgetown medical students.

With momentum growing in CAM, NIH sought to support more education and research in the field. In 2001, the national center awarded Georgetown a $1.7 million grant to develop a plan to incorporate complementary medicine into the medical school curriculum.

Haramati recalls some uncertainty around the method for how to actually make it happen. “We were walking a path where the advocates were saying, ‘You’ve got to do more,’ while skeptics were saying, ‘What are you doing teaching nonsense?’” he recalls. “And we were going down the path saying, ‘We’re going to look at this objectively.’”

In 2002, faculty began to weave aspects of integrative medicine into basic science courses, with some topics explored in-depth as electives. In 2003, Georgetown introduced a one-year master’s program in physiology with CAM, the first degree in science with a focus on complementary medicine offered at a conventional academic medical center in the U.S.

WHERE’S THE SCIENCE?

When the CAM mini-med school began, Amri was studying the effects of saw palmetto on prostate cancer and Ginkgo biloba on stress in the department of cellular and molecular biology. She noted the growing public interest in the field of integrative medicine, but in her view, something was missing.

“I realized that, in my research, I was using top-notch technology in the biomedical sciences,” says Amri. “You name it—PCR gene expression, animal studies, cell culture. I’m using all this here, to study a plant extract. What was really missing from the field of complementary and alternative medicine was this hardcore science.”

Georgetown carefully designed the CAM curriculum to emphasize an evidence-based, scientific, critical but open-minded look at integrative medicine.

The exposure to CAM in both the master’s program and in the medical school curriculum is not designed to advocate or promote complementary medicine, Amri says, but to train the next generation of researchers and practitioners to understand it. “Because we are scientists in a medical center, the goal is to nurture critical thinking in the students,” she explains. With a broad and deep knowledge of the different complementary modalities, graduates of the program are able to analyze the research, distinguish between a good and bad study, and be critical of what is published.

“And be really anchored in the science,” adds Amri.

WIDE-OPEN MINDS, WIDE-OPEN EYES

In the master’s program today, 25-30 students graduate each year to follow a variety of pursuits including allopathic medicine, naturopathic medicine, dentistry, pharmacology and research. They study human physiology, biochemistry, pharmacology and evidence-based medicine. The students also take an overview course covering CAM disciplines from the U.S. and around the world, including acupuncture and other traditional Chinese medicine, Ayurveda form India, the Unani system of Greco-Arabic-Islamic medicine, pharmacognosy, naturopathy, homeopathy and the physiology of mind-body medicine, given by Michael Lumpkin, Ph.D., former chairman of the department of physiology and biophysics, where the program started.

Students come into the program with a range of preconceived ideas and cultural experiences in complementary medicine. Amri has had students who grew up being treated only with homeopathy, or only with herbs, who want to understand how it works. Some students say every nonconventional therapy they have tried has been effective, but then realize the science does not support some of their experiences. They learn to analyze the studies, ask questions and seek conclusions based on scientific ground.

“On the other end of spectrum,” she says, “I’ve had students who have worked in big pharma, and they sit in the back of the class with their arms folded. I see them and think: I’m not going to influence anybody. I’m just going to deliver the material, with objectivity and rigor—that’s our mission— and see how it’s going to be perceived.” And often Amri sees those students come to the middle. “They say, ‘I think I can understand how the plants work because I understand the mechanisms of drugs, and it could be working on this receptor and that receptor,’ and they see some sense to that.”

Amri enjoys seeing students open their minds to new concepts. Learning disciplines like homeopathy may require students to radically disregard their previous understandings about receptors and responses in toxicology, for example. “I tell students that for the next few hours, put aside all they have learned in biochemistry, pharmacology and cell biology—empty their brains—because homeopathy is a completely different concept. Then I see big eyes on their faces!” laughs Amri.

“We are not teaching them how to treat and diagnose,” says Amri. “We are teaching them how to evaluate the science of the therapy, critically analyze it and learn about these medical systems in the most open-minded way. We want them to make informed decisions about their career and later with their patients.”

MIND-BODY MEDICINE TAKING HOLD

As the founders of this initiative continued to develop the complementary medicine curriculum, they looked to bring an experiential element to the students along with the didactic approach. The mind-body medicine program evolved from that interest.

The course has three principle objectives, explains the program’s director, Nancy Harazduk, M.Ed., M.S.W. One goal is to enhance self-care and self-awareness so that the students will lead a balanced life and become more mindful physicians. The course also aims to help busy medical students manage and reduce their own stress by introducing them to a variety of mindbody skills. Third, the program aims to create supportive and compassionate relationships among students, faculty and staff.

Some of the skills taught in the program include meditation, guided imagery, autogenic training (selfhypnosis), biofeedback and healing through journaling, drawing and movement. The course is offered as an elective, meeting once a week for a two-hour session over 11 weeks. The close-knit groups are limited to 10 students with two trained faculty facilitators. Students spend the first hour of each session building connections, checking in with each other and creating a space for compassion in an atmosphere of non-judgment, explains Harazduk. The second hour is spent learning a new mind-body skill.

Students take the program during the second half of their first year, but many come back for more, continuing with their group in some cases for all four years. The calm and supportive environment offers a welcome change in an otherwise intense time in their lives. Led by adept and compassionate facilitators—many of whom the students see in other teaching roles in the school—the small group mind-body sessions teach students skills that as physicians they will use again and again: how to slow down, be fully present, and build meaningful relationships.

The mission of the mind-body medicine program aligns with cura personalis, says Harazduk. “Holistic medicine treats the emotional, physical, social and spiritual aspects of a person. When someone has a heart attack, you ask what caused it: what are your relationships like, what is your work like, can stress be a part of it? When they become physicians, students who practice mind-body medicine will look at patients this way. What is the root of the problem? That’s what they want to heal, and that’s what I hope to teach.”

Since it began in 2002, over 1200 students have taken the mind-body course, and over 90 clinicians, researchers and educators on the faculty have been trained as facilitators. In addition, the program is now offered to students at the School of Foreign Service and the Law Center.

Harazduk believes that while not in the mainstream yet, use of mind-body medicine is growing, and that the use of complementary medicine in addition to allopathic is best for the patient.

“The goal is to have physicians who are aware of not just the physical but the emotional, social and spiritual aspects of a disease—and treat them all,” says Harazduk. “If they’re not able to do this alone, these physicians will respect and give credibility to the other practitioners who can help. Truly integrative medicine is not quite here yet, but things are much better than when I started 13 years ago. Its time is coming.”

FROM ALTERNATIVE TO INTEGRATIVE

Earlier this year, NIH changed its research center’s name to the National Center for Complementary and Integrative Health (NCCIH), dropping the “alternative” and inserting “integrative.” What’s the difference?

According to NIH, alternative medicine is defined as “unproven practices used in place of conventional medicine.” And this kind of practice, they say, is rare. Integrative care, on the other hand, brings together the traditional Western medical practices and the complementary therapies—a trend that is growing.

“We have called it CAM—complementary and alternative medicine—but it’s not alternative to medicine,” explains Haramati. “It is part of medicine.”

With NIH moving away from the alternative terminology, look for other leading national institutions—including Georgetown—to do the same.

Since the early years of complementary medicine research and education at Georgetown, the university has held a critical place on the national scene. Hosting multiple cross-disciplinary dialogues, Georgetown has convened chiropractors and conventional doctors, acupuncturists and anesthesiologists to advance the science-based study of integrative medicine. In 2002, Haramati and Lumpkin helped found the Consortium of Academic Health Centers for Integrative Medicine—along with leaders from 10 other institutions including Harvard, Stanford and UCSF—with a mission to advance the principles and practices of integrative healthcare within academic medical centers.

“Georgetown has been a catalyst in the national study of integrative medicine,” says Haramati. “We’ve made it credible to ask the questions and have the conversation.”

Over the past 15 years, the way CAM has been taught at Georgetown has evolved, but the goals have remained constant: to train students to objectively and rigorously assess the safety and efficacy of various modalities, and explain the mechanistic basis for therapies like acupuncture, massage, herbs and supplements, and mind-body interactions.

“With cura personalis, the patient is at the center. How can you not look at options outside of Western medicine? You have to,” asserts Haramati, who calls himself an open-minded skeptic. “If we approach complementary medicine scientifically, there is no question we can’t ask. As my colleague articulates, ‘We should be bold in our questions, but cautious in our conclusions.’ We study what is happening and then make conclusions about why. And we need to be prepared to have our closest-held beliefs disproved.”

By Jane Varner Malhotra