Reflections on Education, Information and Informed Choice in Complementary and Alternative Health Care (February 4, 2002)

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Table of Contents

• Introduction
• Themes from the Introduction
• Education of Conventional Health Care Practitioners about Complementary and Alternative Health Care
• Education of Complementary and Alternative Health Care Providers
• Building formal/informal links between conventional care and complementary and alternative health care for information sharing/education/curriculum
• Education/information for the public
• Building Networks
• Appendix 1

Introduction

On February 4, 2002, a meeting of a group of experts in the area of education and information issues on complementary and alternative health care (CAHC) was convened in Ottawa by the Health Human Resource Strategies Division, Health Policy and Communications Branch, Health Canada. The purpose of the meeting was to:

• review and reflect on current activities on education and curriculum issues related to CAHC - both for health sciences faculties and for CAHC educators
  
• propose and prioritize areas for continuing or future attention, in a 2002/2003 and 2003/2004 time frames
• consider information and informed choice issues in the context both of public education and practitioner education
• suggest priority areas for future attention in relation to the above
• share information

The participants of the meeting are found in Appendix 1.

Through the process of a pre-meeting consultation and as a result of the meeting discussion, the group identified four strategic areas related to education and information issues: education of conventional health care practitioners about CAHC; education of CAHC providers; building formal/informal links between conventional care and CAHC for information sharing/education/curriculum; and education/information for the public. A summary of this information is presented below.

Themes from the Introduction

The group began by sharing the work that they have been involved in regarding education and information in CAHC. The following themes arose from this discussion.

How can we most powerfully connect and collaborate?

There are a number of initiatives going on across Canada in the area of education and information on complementary and alternative health practices. Many impressive initiatives have been developed and carried out. Often, the most successful ones have been small, grassroots undertakings. One of the primary reasons for their success is that they started small and slowly at the grassroots level. It is critical that individuals (such as those at the meeting) and groups collaborate to share and learn from these initiatives. There needs to be a number of strategies to share information at a variety of levels - for example, through national associations (keeping in mind that not all groups are well organized and represented nationally); through provincial collaboration; and through electronic communication. These and other suggestions were explored throughout the day.

The need for infrastructure

The group noted that there is currently no infrastructure to support education, information and informed choice in the area of CAHC. There is a need for infrastructure to support the development of research, education, regulation, standards, roles and core competencies in CAHC practice.

The definition of evidence

There is much controversy regarding the question, 'what is evidence?'. There is a continuum of evidence from randomized clinical trials to 'best practices' and to 'clinical wisdom'. There is a lack of agreement within and among many groups as to what constitutes evidence.

Facilitating grassroots initiatives

Participants identified that much of the progress that they have made and the success that they have had in educating conventional professionals regarding complementary and alternative health practices and products have been the result of working one-on-one, of teaching by demonstration, but enabling conventional providers to experience what alternative and complementary providers have to offer. These are grassroots initiatives that are very experiential in nature. They were successful because they started small and built on that experience. It would be very valuable to build consortia of these experiences and successes. In addition, it would be important to identify and nurture champions that arise out of these experiences.

Getting the word out

A number of group members were involved in initiatives related to 'getting the word out.' For example, the Ontario Chiropractic Association has established a 'road show' that describes their profession's practice. The Tzu Chi Institute for Complementary and Alternative Medicine has developed a number of important documents and initiatives - such as "Navigating the System," which is intended to help people understand the world of CAHC practice and products. Initiatives such as these need to be disseminated and built upon so that others can learn from these experiences.

Education of Conventional Health Care Practitioners about Complementary and Alternative Health Care

The group reviewed some of the initiatives taking place with regard to the education of conventional health care practitioners. The knowledge level among conventional health care professionals regarding CAHC practices varies. Nevertheless, it was generally felt that interest in CAHC on the part of conventional practitioners is creating a demand for education and training. Some courses are being provided by health care faculties in Canadian universities; however, there is much more that needs to be done. A survey of medical and nursing faculties in Canada found that eight of the nine medical schools offered courses that included information on CAHC, as did 28 of the 31 nursing schools that participated in the survey. However, only one medical school and seven nursing schools offered full courses on CAHC. In addition, it was recognized that there is a certain degree of opposition to CAHC within the university educational system. While conventional providers do state that there should be better standards of education for CAHC practitioners, there are often blocks to integration into the system.

In May 2001, a half-day plenary session at the Association of Canadian Medical College's (ACMC) annual meeting, entitled "What Our Future Doctors Need to Know About Alternative/Complementary Medicine," was presented and attended by 150 to 200 medical school educators. As part of the plenary planning, an e-mail survey of medical educators was conducted to assess their opinions and beliefs about the role of complementary and alternative medicine (CAM) in undergraduate medical education in Canada. Most respondents believed that there is a role for CAM in undergraduate medical education. The most appropriate roles for physicians with respect to CAM were identified as having a basic understanding of the CAM approaches patients were using; being willing to discuss CAM with patients; being able to identify safety risks; and having a basic understanding of the evidence base of CAM. The challenges to including CAM in undergraduate medical education identified were significant. They included limited curriculum time; lack of credible, well-informed faculty; and lack of evidence for CAM.

The medical educators noted that some of the challenges could be overcome by positioning CAM teaching in the context of responding to patient needs; using evidence-based presentations; focusing on cultural rather than technical issues; and using integrated rather than stand-alone teaching methods. The medical educators supported a model of CAM education that would be evidence-based and would use case- and problem-based teaching strategies. They recommended a proactive, rather than a reactive, approach by the Undergraduate Medical Education Deans and curriculum committees, along with faculty development, legitimization by accreditation bodies, and the use of local champions.

As part of the follow-up, the University of Calgary in fall 2001 agreed to take a leadership role with Health Canada and the ACMC with regard to continuing the work in undergraduate medical curriculum. They plan to study curriculum to define the content and scope of CAM approaches, to look at innovative approaches and to start work on curriculum model development. A scan has been conducted at the medical faculties at the Universities of Calgary, Saskatchewan and Manitoba. The scan examines what specifically is being taught in courses, and will examine what needs to be taught. At the next meeting of the ACMC, the group at Calgary will meet with all Associate Deans and Curriculum Chairs to explore this further - a small questionnaire will be developed and given to the group in advance.

The group noted that while this was an important initiative in the medical profession, it was equally important to have initiatives in the other conventional professional groups. Barbara Findlay, Executive Director, Tzu Chi Institute has developed workshops for conventional practitioners regarding CAHC practice and practitioners. These workshops bridge the gap between knowledge and the ethics and legal responsibility of conventional practitioners to help them to identify their new role. In addition, she is planning to conduct policy workshops with nurses, managers and administrators to examine how they can make changes at the system and organizational level.

The group identified a number of issues regarding the education of conventional health care professionals, which are summarized as follows.

Needs of conventional health care practitioners

Conventional health care practitioners need to understand the 'lay of the land' - the language of CAHC, the concepts, the levels of evidence regarding products and practice, and the demographics of users and practitioners. Conventional providers also have concerns about their own roles with regard to CAHC. For example, they feel the need to advocate for choice on behalf of their clients; at the same time, they are accountable to their professional standards. They do not always feel that they have the information required to provide full, informed choice and to therefore meet the terms of their professional standards. This was described as the 'evidence-based practice and advocacy' paradox.

The development of core competencies

There is a need to develop core competencies for conventional health care providers with regard to CAHC. These competencies need to include the following components: knowledge, attitudes and skills. Relationship building should be at the top of the list in developing these core competencies - there is a need to examine cultural differences within professions, and cultural differences across professions. Core competencies are needed at two different levels: in undergraduate curricula and for practising professionals in the form of continuing competencies.

In undergraduate curricula, the competencies would address theory or didactic components (knowledge and attitudes) as well as competencies for student placements (skills).

With regard to continuing competencies, the group felt that the model of reflective practice should be considered. Nursing has become particularly involved in reflective practice assessment - a number of jurisdictions have a formal reflective practice process in place that involves both self-reflection and peer review to assess continuing competence. In addition, the group identified that massage therapy and pharmacy also both have a reflective practice process. It was suggested that a number of these models should be pulled together, examined and built upon.

The group felt that it would be beneficial to develop core competencies across disciplines. That is, there could be a small number of basic core competencies that could be shared by all conventional providers, and then more specific, discipline specific, core competencies could be developed. The group suggested that it would be most appropriate to start this work with medicine, nursing and pharmacy and build from there.

Formal dialogue between national associations

National professional associations have a leadership role to play with regard to undergraduate and continuing competencies. In many cases, - for example, nursing, pharmacy, medicine, occupational therapy and physical therapy - a great deal of work has been done. However, these professional associations often work in 'silos' - there is little sharing and communication between them. Therefore, it was suggested that a formal dialogue between national professional associations should be facilitated to enhance information sharing so that common goals concerning core competencies and CAHC could be identified.

Champions

To facilitate the education of conventional providers with regard to CAHC, it will be critical to have champions within the various professions. These champions need to be identified, nurtured and enabled to come together to share experiences and to learn from each other. They will need support, more through experiential opportunities than through formal meetings.

Education of Complementary and Alternative Health Care Providers

CAHC practitioners are in various stages of development with regard to their education. The scope, depth and duration of their education and training vary. Training can be lengthy and comprehensive or may consist of a discrete course. Education programs are provided by private institutes, universities and community colleges.

Assessment of needs in curricula

It was suggested that it would be useful to adapt the questionnaire used with conventional educators so that it could be used to determine how much conventional practice is taught in CAHC practitioner education programs. The core of the questionnaire would be applicable, but some changes would be needed.

Education regarding research

There is a particular need to educate CAHC providers in research. This need is apparent in a number of ways. There is a need to:

• develop a culture or attitude around research within a number of CAHC professions (There is great variation within the professional groups as to the perceived relevance of research - some groups feel that doing research is unnecessary.)
• build research capacity within many CAHC professions
• develop partnerships between practitioners and university based researchers
• develop modules for curricula
• develop research literacy workshops for CAHC professionals
• develop the full continuum of research 'more than RCTs' - to include process as well as outcome research
• train a few practitioners to become mentors (This could be done through seed money and research fellowships.)
• develop research workshops for community-based practitioners

Champions

As with conventional practitioners, there is a need to develop champions within CAHC professional groups. As with conventional practitioners, these champions need to be identified, nurtured and enabled to come together to share experiences and learn from each other. They will need support, more in the form of experiential kinds of opportunities than through formal meetings.

Building formal/informal links between conventional care and complementary and alternative health care for information sharing/education/curriculum

Formal dialogue between national associations

There is a need for formal dialogue between national associations - those representing conventional practitioners and those representing CAHC practitioners. The group recognized that this is complicated, as a number of CAHC professions are not organized nationally and, furthermore, a number of them are not represented by only one group, but rather by a number of groups.

Sector Study

It was suggested that the sector study initiative was seen as having potential to move towards collaboration among CAHC groups. In March 2001, Health Canada, in conjunction with Human Resources Development Canada (HRDC), hosted a meeting of selected CAHC practitioners for a preliminary discussion on the feasibility of a sector study in this area of health care. Six areas were proposed as a starting point for discussions with HRDC: acupuncture, chiropractic, homeopathy, massage therapy, naturopathy and traditional Chinese medicine. All six groups were represented at the meeting. At the March meeting, a number of key potential benefits to a sector study were identified: one of these was that the study would enhance communication and collaboration within the sector. The group has continued to work on the feasibility of the sector study.

Provincial

The group identified that it will be important to mobilize the provincial ministries of Health. Group members saw a need to identify the contact people are within the ministries and to encourage their meeting/working together. It was noted that there are four federal/provincial/territorial committees that could be accessed: Health Services, Human Resources, Health Information and Population Health. A suggested possible first step could be a brainstorming session with provincial government representatives. An important link could be made between CAHC and health promotion/primary health care.

Education/information for the public

The group did not discuss this fourth issue at the meeting; however, they identified it as critical through the process of the agenda building questionnaire. The group felt that a great deal of groundwork had been done already - for example, at the November 2000 invitational seminar convened by the Health Systems Division, Health Canada. That seminar identified a number of critical building blocks toward providing information to users and enabling them to make informed choices on the basis of that information. The building blocks were terminology and language; sources of information; modes of communication; evidence; professional competency; and relationships with and within the health care system.

The group identified two other important issues related to information and informed choice for the public. They felt it was critical to:

• develop a single (Canadian) credible source of information about CAHC for the public
• strengthen consumer/public knowledge/empowerment

Building Networks

One of the common themes of the day was the need for collaboration and working together - between national associations of CAHC and conventional providers, between provincial jurisdictions, between educational centres and between individuals. Therefore, the group noted that priority should be given to the development of a network of individuals and groups working in and committed to CAHC. In addition, they identified the need for a working group of Health Canada that focuses specifically on education and information issues.

Network

The group identified that the concept of a network has come up at virtually every meeting on CAHC that has been held in the last couple of years.

The group recommended that Health Canada initiate an examination of the national reports that have recently been written on CAHC and to create a synthesis document that specifically examines the concept of developing a network. Health Canada would be able to support this financially and the group around the table would act in an advisory capacity to the report's development.

There are a number of upcoming opportunities that could be seized to move this concept along, as well as a number of important concepts to remember. They are summarized below.

• The network concept should be identified as a priority at the upcoming Natural Health Products Directorate (NHPD) /Canadian Institutes of Health Research (CIHR) funded Priorities Conference.
• A small planning group could then draft a proposal for such a network, outlining the objectives and structure that could be vetted through a larger group.
  
• There is a meeting proposed in June to examine the underlying principles and concepts of integrative medicine - perhaps a group could meet following that meeting.
• it will be important to brainstorm with the National Institutes of Health (NIH) in the US, which has experience in establishing a network, and to ask a number of questions: What worked? What failed? How can we learn from their successes and mistakes?
• Once a proposal for a network is developed, it could be taken to a number of funders: CIHR; Natural Sciences and Engineering Research Council of Canada (NSERC); the Social Sciences and Humanities Research Council (SSHRC); professional associations; governments and private foundations.
• It will be important to look at the strengths of the networks/groups that already exist across the country, to use and build upon what exists - for example, the Toronto CAM network, the newly developing network in Calgary, the group that came together around the White Paper, and the proposed consortium around integrative care.

Working Group

The group suggested that there is a need for a Health Canada working group on education, research and information. It was proposed that a reasonable size for the group would be eight members and that it would include both practitioners - conventional and CAHC - and those who work with a product focus. This would be a 'working group' - that is, it would be mandated to accomplish specific tasks/objectives, as opposed to having an advisory capacity. It should be given a time-line.

Appendix 1

Meeting Participants

Patricia Dryden
Massage Therapy Program
Applied Arts and Health Sciences
Centennial College
Scarborough, ON

Marja Verhoef
Department of Community Health Sciences
Faculty of Medicine
Calgary, AB

Barbara Findlay
Tzu Chi Institute for Complementary & Alternative Medicine,
Vancouver, BC

Heather Boon
Faculty of Pharmacy
University of Toronto
Toronto, ON

Silvano Mior
Canadian Memorial Chiropractic College
Toronto, ON

Health Canada staff

Joan E. Simpson (regrets)
Health Human Resource Strategies Division
Health Canada
Ottawa, ON

Michael J. Smith
Natural Health Products Directorate
Health Canada
Ottawa, ON