Development of an Integrative Medicine Rotation for Family Medicine and Preventive Medicine Residency

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Development of an Integrative Medicine Rotation for Family Medicine and Preventive Medicine Residency

Author(s)
Marissa Khajavi, MD, MPH
Delia Chiaramonte, MD, MS
Beth Hogans, MD, PhD
Jacob Blumenthal, MD, FACP
Leslie Katzel, MD, PhD
Jeffrey Beans, MPH, MBA
Jamie Giffuni, MA
Elizabeth A. Dennis, PhD, RD

Integrative medicine or complementary alternative medicine (IM/CAM) is increasingly being recognized as an integral part of optimal health and healing. IM/CAM “reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, healthcare professionals and disciplines.”1 IM/CAM encompasses a wide range of therapies, conceptual frameworks, and health care-related professions, such as acupuncture, massage, dietary supplements, mindfulness, yoga, meditation and guided imagery.1 Research has found that 30% to 98% of patients with chronic conditions seek IM/CAM therapies.1-3

Despite the high prevalence of patients utilizing IM/CAM therapies and the National Institutes of Health grants for IM/CAM education, implementation of IM/CAM instruction in graduate medical education programs remains inconsistent.1 Barriers cited by programs include a lack of IM/CAM experts in the program, faculty training, competing financial resources, and an already full resident education schedule.4 As a result, many physicians have limited or no training in IM/CAM.1,5

The US Department of Veterans Affairs (VA) offers IM/CAM health programs to veterans and caregivers as part of its whole health care initiative.6 Several VA health care systems have adopted whole health and IM/CAM through programs for mental health integration into primary care; women’s health; integrative pain care; geriatrics, through adoption of Age-Friendly Health Systems standards; and nutrition and physical activity.7-13 The VA provides training to more medical students than any other health system: > 95% of US medical schools are affiliated with a VA medical center (VAMC).14 As part of the training mission, VA seeks to encourage students of diverse professions to consider careers in the VA.14

Residency is a time for newly licensed physicians to acquire additional experience and training to translate knowledge and skills acquired during medical school directly to patient care.15 However, residency curricula have limited time to incorporate IM/CAM training. Residency training is also physically and psychosocially demanding, often resulting in inadequate self-care, poor work-life balance, and disrupted sleep.16-18 Resident wellness is at a historic low, resulting in high rates of burnout during training.4,15

Residency programs are required to provide wellness education; however, most programs include minimal content.19 Despite high rates of burnout, formal curricula on the topic have not been established. 20 IM/CAM education also can provide a path for residents to learn about and engage in mindfulness-based training or cognitive stress reduction for self-care.

INTEGRATIVE WHOLE HEALTH ROTATION

In 2017, the Baltimore Geriatric Research Education and Clinical Center (GRECC) established an IM/whole health residency rotation and created a structured curriculum incorporating self-assessment, active reflection, and self-care to complement training in specific IM/CAM modalities for residents in family medicine. The curriculum evaluated how this training improved residents’ perceptions of IM/CAM and how it personally and professionally impacted the practice of self-care as a strategy to decrease burnout. We hypothesized that this structured experience would increase IM/CAM knowledge among clinicians while promoting the importance and practice of self-care to reduce burnout.

The 2-week IM/CAM curriculum was developed by University of Maryland School of Medicine faculty in partnership with the Baltimore GRECC and staff at the VA Maryland Health Care System. The curriculum was designed to expose residents to the 8 components of the whole health Circle of Health (moving the body; surroundings; personal development; food and drink; recharge; family, friends, and coworkers; spirit and soul; and power of the mind) in addition to IM/ CAM modalities the VA is mandated to offer to veterans (acupuncture, chiropractic, meditation, massage therapy, biofeedback, clinical hypnosis, guided imagery, yoga, and tai chi).21 Twelve residents (1 preventive medicine and 11 third-year family medicine residents) rotated individually throughout the year as part of their behavioral health block rotation. All residents completed the 2-week curriculum as their schedules allowed. The curriculum consisted of didactics sessions and activities at the Baltimore, Loch Raven, and Perry Point VAMCs. Residents completed evaluations before and after the rotation. The experience described in this article by the residents and the survey data were collected from the 2018/2019 training year. A rotation syllabus, competencies adapted from Locke and colleagues and skills residents obtain during this rotation that support these competencies, as well as a resident sample schedule were developed (eAppendix is available at doi:10.12788/fp.0544).1

FDP042035_App
Rotation Overview

for each resident were built around instructional opportunities, which included 1-on-1 didactics, direct observation of treatment modalities, and personal reflection of the residents’ self-care practices. While each resident’s rotation schedule varied slightly due to their schedules, the foundational instruction elements were the same. Didactic session themes included an overview of IM/CAM, nutrition, narrative medicine, pain psychology, music therapy, chaplain services, motor-cognitive training, and exercise guidelines. Assigned readings, including peer-reviewed literature on IM/CAM therapies, complemented all sessions. Residents created an evidence-supported integrative treatment plan for a patient with a condition of interest to them.

Residents observed clinician-led veteran group sessions on IM/CAM treatment modalities, including guided meditation, mindfulness and relaxation, self-awareness, living well with chronic pain, tai chi, drumming for health and balance, anger management, recovery group, acceptance and commitment therapy, and Gerofit exercise. The group classes allowed residents to actively participate in the activity or discussion. Residents also shadowed VA clinicians in sleep, pain, nutrition, acupuncture, and mental health clinics.

Residents were encouraged to practice self-care during the 2-week rotation. The rotation schedule built in free time, including a 1-hour daily lunch period, for residents to consider their own health habits, complete a personal health inventory, and try self-care activities outlined on the syllabus with links to resources. These resources also served as educational materials that residents could share with patients. All materials, including didactic lectures, journal articles and self-care resources, were provided to each resident through a free online course to ensure residents had access throughout and following completion of the rotation. This content, including the rotation evaluation metrics, is available upon request from the corresponding author.

Evaluations

Residents completed a survey before and after the rotation to measure IM/CAM knowledge and application and self-care/ burnout perceptions. Residents were asked to evaluate rotation sessions and comment on whether this rotation benefited them personally and professionally (Table 1). Descriptive statistics were analyzed using Microsoft Excel. Given the small sample size and lack of statistical power, only mean survey results are reported in this article. Because this opportunity is specific to the University of Maryland School of Medicine and the proposed project was part of ordinary educational practice, the study was deemed not human subject research by the University of Maryland Institutional Review Board (HP-00089256).

FDP042035_T1

Perceptions and attitudes toward IM/CAM were assessed using a survey designed by the University of Minnesota Academic Health Center. It included 18 items scored on a 5-point semantic rating scale (1, strongly disagree; 5, strongly agree).22 Residents rated their level of agreement with statements reflecting both positive (eg, clinical care should integrate the best of conventional and CAM practices) and negative (eg, CAM is a threat to public health) views. Three questions adapted from the NHIS Adult Complementary Health Questionnaire and UC Irvine Survey of Health Care Use and Practice assessed the use of IM/CAM resources.23,24

Resident knowledge and application of IM/CAM were measured using a case study designed by the course faculty. The case listed a chief complaint of nerve pain, with a history of chronic pain, neuropathic pain, anxiety, chronic fatigue, depression, insomnia, posttraumatic stress disorder, history of present illness, past surgical history, medication list, review of symptoms, laboratory values, and physical examination. The residents completed an assessment before and after the rotation. Residents rated their confidence in the diagnosis and treatment of 8 medical conditions using a 5-point semantic rating scale (Table 2). Self-care importance and selfcare frequency were measured by a variety of means, including 3 survey questions, the Five Facet Mindfulness Questionnaire, 2 prompts on a 7-point semantic scale, and a slightly modified version of the validated Perceived Stress Scale.25-28

FDP042035_T2
Survey Results

Residents gave the rotation positive feedback with a mean score of 8.5 out of 10. They reported the beneficial impact of seeing the nontraditional and nonpharmacological practices in treating patients, chronic pain management team approaches, and enjoyed being able to participate in group classes with patients. Many residents expressed a desire for a longer rotation to have more time to experience the behavioral health-focused sessions. Residents also requested additional information on nutritional supplements/natural medicines, battlefield acupuncture training and osteopathic manipulative therapy practices. All residents reported the rotation personally and/or professionally benefited them (Appendix).

Given the sample of 12 residents, values are presented as prerotation to postrotation comparisons without statistical analysis. There was a trend towards an increase in the reported use and recommendation of 26 modalities of nonconventional therapies following the rotation. There was also a slight increase in resource knowledge and use of these resources, and residents reported accessing more types of resources. Mean scores of the case study to gauge knowledge and application of IM increased from 7.5 at baseline to 11.0 after the rotation. Resident confidence in diagnosis increased for all 8 conditions, but confidence in treatment only increased for 4 conditions.

Results of self-care importance, self-care frequency and mindfulness were consistent baseline to postrotation. The mean time residents spent regularly practicing self-care during a work week increased slightly while feelings of burnout decreased. The perceived stress scale average score decreased from 13.4 at baseline to 10.5 after rotation.

DISCUSSION

The implementation of an IM residency rotation that incorporates whole health and interprofessional practices demonstrated improved perception and increased use of IM/CAM resources and knowledge among a small sample of third-year residents. Residents reported they had a positive experience participating in the rotation and gained knowledge, resources, and skills they felt confident discussing with their patients.

Many studies reported favorable attitudes and perceptions of IM/CAM use among physicians, but few have assessed these measures while implementing a training curriculum.3,4,22 Gardiner and colleagues reported on the perception and use of IM resources among family medicine residents.4 The study found that while 58% of all residents reported IM/CAM as an important part of their training, only 60% reported they received it or had specific learning objectives in their curriculum. 4 The program outlined in this study and previous research illustrate that physicians recognize the importance of IM/CAM education in training programs, but most were unaware of the resources available or did not feel comfortable counseling patients about most IM/CAM applications.

Residents in this program slightly increased their use of IM/CAM to diagnose and treat medical conditions after the rotation. A study by Wahner-Roedler and colleagues assessed physician knowledge regarding common IM/CAM therapies.3 On average, physicians only felt knowledgeable and comfortable counseling patients for 3 of 13 listed treatments/techniques and few natural herbal treatments. The study also found that most physicians had difficulty accessing IM/CAM information at their institution despite having free access to electronic databases. However, this study only assessed physician attitudes of IM/CAM and did not include an educational component to increase their knowledge of the modalities.3 This evaluation supports the need for interventions like the program described in this article that provide physicians with access to evidence-based resources combined with the applied experiences to increase their comfort within this growing field.

Though the sample size in this study was small, its results support existing research indicating that clinicians view selfcare as important. Many residents were already using a self-care plan at baseline, but there was slight increase in the practice of self-care during the rotation and a slight decrease in burnout. Previous research reflects high rates of burnout and relatively poor quality of life among primary care physicians.15 Burnout is associated with lower quality of care, lower patient satisfaction and contributes to medical errors. Studies suggest as many as 60% of primary care physicians report symptoms of burnout, which negatively affected the quality of patient care they provide.15

Despite the profound effects burnout has on physicians and patient care, a standardized wellness education or self-care tool kit is not currently available. The University of Massachusetts recently introduced a pilot program to promote resident wellness that demonstrated favorable results.15 A meta-analysis of physicians and medical trainees found decreases in anxiety and symptoms of anxiety as well as a decrease in burnout among participants in cognitive, behavioral and mindfulness interventions.29 However, unlike our program, these programs focused solely on the well-being of medical trainees, residents, and physicians and didn’t focus on the patient-clinician interactions. Given the impact on patient care, there is a need to develop and implement additional programs like our residency rotation that promote health and wellness among physicians while also evaluating how physicians may translate these skills to patient education.

While this program st i l l exists for third-year residents at Baltimore GRECC, it has significantly changed since the COVID-19 pandemic. For about the first 6 months of the pandemic, when physical distancing requirements were in place, family medicine trainees were not able to rotate. Upon return to the facility, many group classes were cancelled and some clinicians no longer offered the sessions. The rotation has evolved to a hybrid format, where many group classes for veteran patients are offered virtually, and residents observe a mix of virtual and in-person shadowing opportunities. Our formal evaluation included administering the survey and occurred from July 2018 to July 2019 but wasn’t implemented upon return to post-COVID activities due to the inconsistent experiences offered to residents over the past few years. Future research should evaluate the impact of this hybrid program on the clinicians and explore dissemination to other VAMCs and their academic affiliates.

Limitations

Project recruitment was limited to 11 family medicine and 1 preventive medicine resident. Perceptions, use of IM/CAM, and knowledge about IM/CAM could be considerably different in different departments with varying schedules, hours worked, and patient volumes. Secondly, the survey was conducted 2 weeks apart. Indications of self-care and burnout may not reflect long-term effects, adoption, or maintenance. Future research should include longer follow up to examine how this type of educational activity may impact burnout rates of physicians following the completion of residency, as well as changes in perspectives of IM/CAM while practicing as a physician. Trainees were exposed to a wide range of health care professions, but additional research is needed regarding medical resident perceptions of the roles of specific professions in a collaborative health care team.30,31

CONCLUSIONS

The residency rotation program illustrates the benefits of establishing a standardized IM/CAM rotation that includes self-care resources in family medicine programs to adequately train clinicians to practice wellness and promote it to their patients. The results of this project suggest this type of training will help residents assess the literature to better counsel patients on IM/CAM options while also providing strategies for maintaining optimal health and well-being for health care professionals. Broadening and shifting the scope of medicine from treatment to prevention, personal wellness, and optimal healing should be a top priority.

References
  1. Locke AB, Gordon A, Guerrera MP, Gardiner P, Lebensohn P. Recommended integrative medicine competencies for family medicine residents. Explore (NY). 2013;9(5):308-313. doi:10.1016/j.explore.2013.06.005
  2. Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. JAMA. 1998;280(18):1569-1575. doi:10.1001/jama.280.18.1569
  3. Wahner-Roedler DL, Vincent A, Elkin PL, Loehrer LL, Cha SS, Bauer BA. Physicians’ attitudes toward complementary and alternative medicine and their knowledge of specific therapies: a survey at an academic medical center. Evid Based Complement Alternat Med. 2006;3(4):495-501. doi:10.1093/ecam/nel036
  4. Gardiner P, Filippelli AC, Lebensohn P, Bonakdar R. Family medicine residency program directors attitudes and knowledge of family medicine CAM competencies. Explore (NY). 2013;9(5):299-307. doi:10.1016/j.explore.2013.06.002
  5. Sierpina V, Levine R, Astin J, Tan A. Use of mind-body therapies in psychiatry and family medicine faculty and residents: attitudes, barriers, and gender differences. Explore (NY). 2007;3(2):129-135. doi:10.1016/j.explore.2006.12.001
  6. Krist AH, South-Paul J, Meisnere M, eds. Achieving Whole Health: A New Approach for Veterans and the Nation. The National Academies Press; 2023.
  7. Bokhour BG, DeFaccio R, Gaj L, et al. Changes in patientreported outcomes associated with receiving whole health in the Veteran Health Administration (VHA)’s National Demonstration Project. J Gen Intern Med. 2024;39(1):84-94. doi:10.1007/s11606-023-08376-0
  8. Courtney RE, Schadegg MJ, Bolton R, Smith S, Harden SM. Using a whole health approach to build biopsychosocial- spiritual personal health plans for veterans with chronic pain. Pain Manag Nurs. 2024;25(1):69-74. doi:10.1016/j.pmn.2023.09.010
  9. Gabrielian S, Jones AL, Hoge AE, et al. Enhancing primary care experiences for homeless patients with serious mental illness: results from a national survey. J Prim Care Community Health. 2021;12:2150132721993654. doi:10.1177/2150132721993654
  10. Matthieu MM, Church KA, Taylor LD, et al. Integrating the age-friendly health systems movement in Veterans Health Administration: national advance care planning via group visits and the 4Ms framework. Health Soc Work. 2023;48(4):277-280. doi:10.1093/hsw/hlad022
  11. Meisler AW, Gianoli MO, Na PJ, Pietrzak RH. Functional disability in US military veterans: the importance of integrated whole health initiatives. Prim Care Companion CNS Disord. 2023;25(4):22m03461. doi:10.4088/PCC.22m03461
  12. Ortmeyer HK, Giffuni J, Etchberger D, Katzel L. The role of companion dogs in the VA Maryland Health Care System Whole Health(y) GeroFit Program. Animals (Basel). 2023;13(19):3047. doi:10.3390/ani13193047
  13. Sullivan MB, Hill K, Ballengee LA, et al. Remotely delivered psychologically informed mindful movement physical therapy for pain care: a framework for operationalization. Glob Adv Integr Med Health. 2023;12:27536130231209751. doi:10.1177/27536130231209751
  14. (OAA) OoAA. 75th Anniversary: Passion to learn. Power to heal. Washington DC.: US Department of Veterans Affairs; 2021. https://content.yudu.com/web/448fx/0A448g9/75thAnniversary2021/html/index.html?page=24&origin=reader
  15. Runyan C, Savageau JA, Potts S, Weinreb L. Impact of a family medicine resident wellness curriculum: a feasibility study. Med Educ Online. 2016;21:30648. doi:10.3402/meo.v21.30648
  16. Lafreniere JP, Rios R, Packer H, Ghazarian S, Wright SM, Levine RB. Burned out at the bedside: patient perceptions of physician burnout in an internal medicine resident continuity clinic. J Gen Intern Med. 2016;31(2):203-208. doi:10.1007/s11606-015-3503-3
  17. Freedy JR, Staley C, Mims LD, et al. Social, individual, and environmental characteristics of family medicine resident burnout: a CERA study. Fam Med. 2022;54(4):270-276. doi:10.22454/FamMed.2022.526799
  18. Alrishan MA, Alshammari SA. Prevalence of sleep deprivation and its effect on the performance of family medicine residents in Riyadh, Saudi Arabia. J Family Community Med. 2020;27(2):125-130. doi:10.4103/jfcm.JFCM_9_20
  19. ACGME. ACGME Program Requirements for Graduate Medical Education in Family Medicine. https://www.acgme.org/globalassets/pfassets/programrequirements/120_familymedicine_2024.pdf
  20. Nene Y, Tadi P. Resident Burnout. In: StatPearls; 2023.
  21. Bokhour BG, Haun JN, Hyde J, Charns M, Kligler B. Transforming the veterans affairs to a whole health system of care: time for action and research. Med Care. 2020;58(4):295-300. doi:10.1097/MLF.0000000000001316
  22. Kreitzer MJ, Mitten D, Harris I, Shandeling J. Attitudes toward CAM among medical, nursing, and pharmacy faculty and students: a comparative analysis. Altern Ther Health Med. 2002;8(6):44-53.
  23. Clarke TC, Black LI, Stussman BJ, Barnes PM, Nahin RL. Trends in the use of complementary health approaches among adults: United States, 2002-2012. Natl Health Stat Report. 2015(79):1-16.
  24. Nguyen J, Liu MA, Patel RJ, Tahara K, Nguyen AL. Use and interest in complementary and alternative medicine among college students seeking healthcare at a university campus student health center. Complement Ther Clin Pract. 2016;24:103-108. doi:10.1016/j.ctcp.2016.06.001
  25. Baer RA, Smith GT, Hopkins J, Krietemeyer J, Toney L. Using self-report assessment methods to explore facets of mindfulness. Assessment. 2006;13(1):27-45. doi:10.1177/1073191105283504
  26. Baer RA, Smith GT, Lykins E, et al. Construct validity of the five facet mindfulness questionnaire in meditating and nonmeditating samples. Assessment. 2008;15(3):329-342. doi:10.1177/1073191107313003
  27. West CP, Dyrbye LN, Sloan JA, Shanafelt TD. Single item measures of emotional exhaustion and depersonalization are useful for assessing burnout in medical professionals. J Gen Intern Med. 2009;24(12):1318- 1321. doi:10.1007/s11606-009-1129-z
  28. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983;24(4):385-396.
  29. Regehr C, Glancy D, Pitts A, LeBlanc VR. Interventions to reduce the consequences of stress in physicians: a review and meta-analysis. J Nerv Ment Dis. 2014;202(5):353-359. doi:10.1097/NMD.0000000000000130
  30. Visser CLF, Ket JCF, Croiset G, Kusurkar RA. Perceptions of residents, medical and nursing students about interprofessional education: a systematic review of the quantitative and qualitative literature. BMC Med Educ. 2017;17(1):77. doi:10.1186/s12909-017-0909-0
  31. Lingard L, Espin S, Evans C, Hawryluck L. The rules of the game: interprofessional collaboration on the intensive care unit team. Crit Care. 2004;8(6):R403-408. doi:10.1186/cc2958
Article PDF
FDP04201035.pdf
Author and Disclosure Information

Marissa Khajavi, MD, MPHa; Delia Chiaramonte, MD, MSb,c; Beth Hogans, MD, PhDd,e; Jacob Blumenthal, MD, FACPa,d; Leslie Katzel, MD, PhDa,d; Jeffrey Beans, MPH, MBAd; Jamie Giffuni, MAd; Elizabeth A. Dennis, PhD, RDa,d

Author affiliations:
aUniversity of Maryland School of Medicine, Baltimore 
bIntegrative Palliative Institute, Baltimore, Maryland 
cUniversity of Maryland School of Pharmacy, Baltimore 
dGeriatrics Research, Education, and Clinical Center, Veterans Affairs Maryland Health Care System, Baltimore 
eThe Johns Hopkins School of Medicine, Baltimore, Maryland

Author disclosures: Dr. Hogans serves as Director-at-Large of the American Academy of Pain Medicine and receives royalties from the American Academy of Neurology. The other authors report no actual or potential conflicts of interest with regard to this article.

Correspondence: Elizabeth Dennis (elizabeth.dennis@ som.umaryland.edu)

Fed Pract. 2025;42(1). Published online January 15. doi:10.12788/fp.0544

Issue
Federal Practitioner - 42(1)
Publications
Federal Practitioner
Topics
Mixed Topics
Page Number
35-41
Sections
Program Profile
Author(s)
Marissa Khajavi, MD, MPH
Delia Chiaramonte, MD, MS
Beth Hogans, MD, PhD
Jacob Blumenthal, MD, FACP
Leslie Katzel, MD, PhD
Jeffrey Beans, MPH, MBA
Jamie Giffuni, MA
Elizabeth A. Dennis, PhD, RD
Author(s)
Marissa Khajavi, MD, MPH
Delia Chiaramonte, MD, MS
Beth Hogans, MD, PhD
Jacob Blumenthal, MD, FACP
Leslie Katzel, MD, PhD
Jeffrey Beans, MPH, MBA
Jamie Giffuni, MA
Elizabeth A. Dennis, PhD, RD
Author and Disclosure Information

Marissa Khajavi, MD, MPHa; Delia Chiaramonte, MD, MSb,c; Beth Hogans, MD, PhDd,e; Jacob Blumenthal, MD, FACPa,d; Leslie Katzel, MD, PhDa,d; Jeffrey Beans, MPH, MBAd; Jamie Giffuni, MAd; Elizabeth A. Dennis, PhD, RDa,d

Author affiliations:
aUniversity of Maryland School of Medicine, Baltimore 
bIntegrative Palliative Institute, Baltimore, Maryland 
cUniversity of Maryland School of Pharmacy, Baltimore 
dGeriatrics Research, Education, and Clinical Center, Veterans Affairs Maryland Health Care System, Baltimore 
eThe Johns Hopkins School of Medicine, Baltimore, Maryland

Author disclosures: Dr. Hogans serves as Director-at-Large of the American Academy of Pain Medicine and receives royalties from the American Academy of Neurology. The other authors report no actual or potential conflicts of interest with regard to this article.

Correspondence: Elizabeth Dennis (elizabeth.dennis@ som.umaryland.edu)

Fed Pract. 2025;42(1). Published online January 15. doi:10.12788/fp.0544

Author and Disclosure Information

Marissa Khajavi, MD, MPHa; Delia Chiaramonte, MD, MSb,c; Beth Hogans, MD, PhDd,e; Jacob Blumenthal, MD, FACPa,d; Leslie Katzel, MD, PhDa,d; Jeffrey Beans, MPH, MBAd; Jamie Giffuni, MAd; Elizabeth A. Dennis, PhD, RDa,d

Author affiliations:
aUniversity of Maryland School of Medicine, Baltimore 
bIntegrative Palliative Institute, Baltimore, Maryland 
cUniversity of Maryland School of Pharmacy, Baltimore 
dGeriatrics Research, Education, and Clinical Center, Veterans Affairs Maryland Health Care System, Baltimore 
eThe Johns Hopkins School of Medicine, Baltimore, Maryland

Author disclosures: Dr. Hogans serves as Director-at-Large of the American Academy of Pain Medicine and receives royalties from the American Academy of Neurology. The other authors report no actual or potential conflicts of interest with regard to this article.

Correspondence: Elizabeth Dennis (elizabeth.dennis@ som.umaryland.edu)

Fed Pract. 2025;42(1). Published online January 15. doi:10.12788/fp.0544

Article PDF
FDP04201035.pdf
Article PDF
FDP04201035.pdf

Integrative medicine or complementary alternative medicine (IM/CAM) is increasingly being recognized as an integral part of optimal health and healing. IM/CAM “reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, healthcare professionals and disciplines.”1 IM/CAM encompasses a wide range of therapies, conceptual frameworks, and health care-related professions, such as acupuncture, massage, dietary supplements, mindfulness, yoga, meditation and guided imagery.1 Research has found that 30% to 98% of patients with chronic conditions seek IM/CAM therapies.1-3

Despite the high prevalence of patients utilizing IM/CAM therapies and the National Institutes of Health grants for IM/CAM education, implementation of IM/CAM instruction in graduate medical education programs remains inconsistent.1 Barriers cited by programs include a lack of IM/CAM experts in the program, faculty training, competing financial resources, and an already full resident education schedule.4 As a result, many physicians have limited or no training in IM/CAM.1,5

The US Department of Veterans Affairs (VA) offers IM/CAM health programs to veterans and caregivers as part of its whole health care initiative.6 Several VA health care systems have adopted whole health and IM/CAM through programs for mental health integration into primary care; women’s health; integrative pain care; geriatrics, through adoption of Age-Friendly Health Systems standards; and nutrition and physical activity.7-13 The VA provides training to more medical students than any other health system: > 95% of US medical schools are affiliated with a VA medical center (VAMC).14 As part of the training mission, VA seeks to encourage students of diverse professions to consider careers in the VA.14

Residency is a time for newly licensed physicians to acquire additional experience and training to translate knowledge and skills acquired during medical school directly to patient care.15 However, residency curricula have limited time to incorporate IM/CAM training. Residency training is also physically and psychosocially demanding, often resulting in inadequate self-care, poor work-life balance, and disrupted sleep.16-18 Resident wellness is at a historic low, resulting in high rates of burnout during training.4,15

Residency programs are required to provide wellness education; however, most programs include minimal content.19 Despite high rates of burnout, formal curricula on the topic have not been established. 20 IM/CAM education also can provide a path for residents to learn about and engage in mindfulness-based training or cognitive stress reduction for self-care.

INTEGRATIVE WHOLE HEALTH ROTATION

In 2017, the Baltimore Geriatric Research Education and Clinical Center (GRECC) established an IM/whole health residency rotation and created a structured curriculum incorporating self-assessment, active reflection, and self-care to complement training in specific IM/CAM modalities for residents in family medicine. The curriculum evaluated how this training improved residents’ perceptions of IM/CAM and how it personally and professionally impacted the practice of self-care as a strategy to decrease burnout. We hypothesized that this structured experience would increase IM/CAM knowledge among clinicians while promoting the importance and practice of self-care to reduce burnout.

The 2-week IM/CAM curriculum was developed by University of Maryland School of Medicine faculty in partnership with the Baltimore GRECC and staff at the VA Maryland Health Care System. The curriculum was designed to expose residents to the 8 components of the whole health Circle of Health (moving the body; surroundings; personal development; food and drink; recharge; family, friends, and coworkers; spirit and soul; and power of the mind) in addition to IM/ CAM modalities the VA is mandated to offer to veterans (acupuncture, chiropractic, meditation, massage therapy, biofeedback, clinical hypnosis, guided imagery, yoga, and tai chi).21 Twelve residents (1 preventive medicine and 11 third-year family medicine residents) rotated individually throughout the year as part of their behavioral health block rotation. All residents completed the 2-week curriculum as their schedules allowed. The curriculum consisted of didactics sessions and activities at the Baltimore, Loch Raven, and Perry Point VAMCs. Residents completed evaluations before and after the rotation. The experience described in this article by the residents and the survey data were collected from the 2018/2019 training year. A rotation syllabus, competencies adapted from Locke and colleagues and skills residents obtain during this rotation that support these competencies, as well as a resident sample schedule were developed (eAppendix is available at doi:10.12788/fp.0544).1

FDP042035_App
Rotation Overview

for each resident were built around instructional opportunities, which included 1-on-1 didactics, direct observation of treatment modalities, and personal reflection of the residents’ self-care practices. While each resident’s rotation schedule varied slightly due to their schedules, the foundational instruction elements were the same. Didactic session themes included an overview of IM/CAM, nutrition, narrative medicine, pain psychology, music therapy, chaplain services, motor-cognitive training, and exercise guidelines. Assigned readings, including peer-reviewed literature on IM/CAM therapies, complemented all sessions. Residents created an evidence-supported integrative treatment plan for a patient with a condition of interest to them.

Residents observed clinician-led veteran group sessions on IM/CAM treatment modalities, including guided meditation, mindfulness and relaxation, self-awareness, living well with chronic pain, tai chi, drumming for health and balance, anger management, recovery group, acceptance and commitment therapy, and Gerofit exercise. The group classes allowed residents to actively participate in the activity or discussion. Residents also shadowed VA clinicians in sleep, pain, nutrition, acupuncture, and mental health clinics.

Residents were encouraged to practice self-care during the 2-week rotation. The rotation schedule built in free time, including a 1-hour daily lunch period, for residents to consider their own health habits, complete a personal health inventory, and try self-care activities outlined on the syllabus with links to resources. These resources also served as educational materials that residents could share with patients. All materials, including didactic lectures, journal articles and self-care resources, were provided to each resident through a free online course to ensure residents had access throughout and following completion of the rotation. This content, including the rotation evaluation metrics, is available upon request from the corresponding author.

Evaluations

Residents completed a survey before and after the rotation to measure IM/CAM knowledge and application and self-care/ burnout perceptions. Residents were asked to evaluate rotation sessions and comment on whether this rotation benefited them personally and professionally (Table 1). Descriptive statistics were analyzed using Microsoft Excel. Given the small sample size and lack of statistical power, only mean survey results are reported in this article. Because this opportunity is specific to the University of Maryland School of Medicine and the proposed project was part of ordinary educational practice, the study was deemed not human subject research by the University of Maryland Institutional Review Board (HP-00089256).

FDP042035_T1

Perceptions and attitudes toward IM/CAM were assessed using a survey designed by the University of Minnesota Academic Health Center. It included 18 items scored on a 5-point semantic rating scale (1, strongly disagree; 5, strongly agree).22 Residents rated their level of agreement with statements reflecting both positive (eg, clinical care should integrate the best of conventional and CAM practices) and negative (eg, CAM is a threat to public health) views. Three questions adapted from the NHIS Adult Complementary Health Questionnaire and UC Irvine Survey of Health Care Use and Practice assessed the use of IM/CAM resources.23,24

Resident knowledge and application of IM/CAM were measured using a case study designed by the course faculty. The case listed a chief complaint of nerve pain, with a history of chronic pain, neuropathic pain, anxiety, chronic fatigue, depression, insomnia, posttraumatic stress disorder, history of present illness, past surgical history, medication list, review of symptoms, laboratory values, and physical examination. The residents completed an assessment before and after the rotation. Residents rated their confidence in the diagnosis and treatment of 8 medical conditions using a 5-point semantic rating scale (Table 2). Self-care importance and selfcare frequency were measured by a variety of means, including 3 survey questions, the Five Facet Mindfulness Questionnaire, 2 prompts on a 7-point semantic scale, and a slightly modified version of the validated Perceived Stress Scale.25-28

FDP042035_T2
Survey Results

Residents gave the rotation positive feedback with a mean score of 8.5 out of 10. They reported the beneficial impact of seeing the nontraditional and nonpharmacological practices in treating patients, chronic pain management team approaches, and enjoyed being able to participate in group classes with patients. Many residents expressed a desire for a longer rotation to have more time to experience the behavioral health-focused sessions. Residents also requested additional information on nutritional supplements/natural medicines, battlefield acupuncture training and osteopathic manipulative therapy practices. All residents reported the rotation personally and/or professionally benefited them (Appendix).

Given the sample of 12 residents, values are presented as prerotation to postrotation comparisons without statistical analysis. There was a trend towards an increase in the reported use and recommendation of 26 modalities of nonconventional therapies following the rotation. There was also a slight increase in resource knowledge and use of these resources, and residents reported accessing more types of resources. Mean scores of the case study to gauge knowledge and application of IM increased from 7.5 at baseline to 11.0 after the rotation. Resident confidence in diagnosis increased for all 8 conditions, but confidence in treatment only increased for 4 conditions.

Results of self-care importance, self-care frequency and mindfulness were consistent baseline to postrotation. The mean time residents spent regularly practicing self-care during a work week increased slightly while feelings of burnout decreased. The perceived stress scale average score decreased from 13.4 at baseline to 10.5 after rotation.

DISCUSSION

The implementation of an IM residency rotation that incorporates whole health and interprofessional practices demonstrated improved perception and increased use of IM/CAM resources and knowledge among a small sample of third-year residents. Residents reported they had a positive experience participating in the rotation and gained knowledge, resources, and skills they felt confident discussing with their patients.

Many studies reported favorable attitudes and perceptions of IM/CAM use among physicians, but few have assessed these measures while implementing a training curriculum.3,4,22 Gardiner and colleagues reported on the perception and use of IM resources among family medicine residents.4 The study found that while 58% of all residents reported IM/CAM as an important part of their training, only 60% reported they received it or had specific learning objectives in their curriculum. 4 The program outlined in this study and previous research illustrate that physicians recognize the importance of IM/CAM education in training programs, but most were unaware of the resources available or did not feel comfortable counseling patients about most IM/CAM applications.

Residents in this program slightly increased their use of IM/CAM to diagnose and treat medical conditions after the rotation. A study by Wahner-Roedler and colleagues assessed physician knowledge regarding common IM/CAM therapies.3 On average, physicians only felt knowledgeable and comfortable counseling patients for 3 of 13 listed treatments/techniques and few natural herbal treatments. The study also found that most physicians had difficulty accessing IM/CAM information at their institution despite having free access to electronic databases. However, this study only assessed physician attitudes of IM/CAM and did not include an educational component to increase their knowledge of the modalities.3 This evaluation supports the need for interventions like the program described in this article that provide physicians with access to evidence-based resources combined with the applied experiences to increase their comfort within this growing field.

Though the sample size in this study was small, its results support existing research indicating that clinicians view selfcare as important. Many residents were already using a self-care plan at baseline, but there was slight increase in the practice of self-care during the rotation and a slight decrease in burnout. Previous research reflects high rates of burnout and relatively poor quality of life among primary care physicians.15 Burnout is associated with lower quality of care, lower patient satisfaction and contributes to medical errors. Studies suggest as many as 60% of primary care physicians report symptoms of burnout, which negatively affected the quality of patient care they provide.15

Despite the profound effects burnout has on physicians and patient care, a standardized wellness education or self-care tool kit is not currently available. The University of Massachusetts recently introduced a pilot program to promote resident wellness that demonstrated favorable results.15 A meta-analysis of physicians and medical trainees found decreases in anxiety and symptoms of anxiety as well as a decrease in burnout among participants in cognitive, behavioral and mindfulness interventions.29 However, unlike our program, these programs focused solely on the well-being of medical trainees, residents, and physicians and didn’t focus on the patient-clinician interactions. Given the impact on patient care, there is a need to develop and implement additional programs like our residency rotation that promote health and wellness among physicians while also evaluating how physicians may translate these skills to patient education.

While this program st i l l exists for third-year residents at Baltimore GRECC, it has significantly changed since the COVID-19 pandemic. For about the first 6 months of the pandemic, when physical distancing requirements were in place, family medicine trainees were not able to rotate. Upon return to the facility, many group classes were cancelled and some clinicians no longer offered the sessions. The rotation has evolved to a hybrid format, where many group classes for veteran patients are offered virtually, and residents observe a mix of virtual and in-person shadowing opportunities. Our formal evaluation included administering the survey and occurred from July 2018 to July 2019 but wasn’t implemented upon return to post-COVID activities due to the inconsistent experiences offered to residents over the past few years. Future research should evaluate the impact of this hybrid program on the clinicians and explore dissemination to other VAMCs and their academic affiliates.

Limitations

Project recruitment was limited to 11 family medicine and 1 preventive medicine resident. Perceptions, use of IM/CAM, and knowledge about IM/CAM could be considerably different in different departments with varying schedules, hours worked, and patient volumes. Secondly, the survey was conducted 2 weeks apart. Indications of self-care and burnout may not reflect long-term effects, adoption, or maintenance. Future research should include longer follow up to examine how this type of educational activity may impact burnout rates of physicians following the completion of residency, as well as changes in perspectives of IM/CAM while practicing as a physician. Trainees were exposed to a wide range of health care professions, but additional research is needed regarding medical resident perceptions of the roles of specific professions in a collaborative health care team.30,31

CONCLUSIONS

The residency rotation program illustrates the benefits of establishing a standardized IM/CAM rotation that includes self-care resources in family medicine programs to adequately train clinicians to practice wellness and promote it to their patients. The results of this project suggest this type of training will help residents assess the literature to better counsel patients on IM/CAM options while also providing strategies for maintaining optimal health and well-being for health care professionals. Broadening and shifting the scope of medicine from treatment to prevention, personal wellness, and optimal healing should be a top priority.

Integrative medicine or complementary alternative medicine (IM/CAM) is increasingly being recognized as an integral part of optimal health and healing. IM/CAM “reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, healthcare professionals and disciplines.”1 IM/CAM encompasses a wide range of therapies, conceptual frameworks, and health care-related professions, such as acupuncture, massage, dietary supplements, mindfulness, yoga, meditation and guided imagery.1 Research has found that 30% to 98% of patients with chronic conditions seek IM/CAM therapies.1-3

Despite the high prevalence of patients utilizing IM/CAM therapies and the National Institutes of Health grants for IM/CAM education, implementation of IM/CAM instruction in graduate medical education programs remains inconsistent.1 Barriers cited by programs include a lack of IM/CAM experts in the program, faculty training, competing financial resources, and an already full resident education schedule.4 As a result, many physicians have limited or no training in IM/CAM.1,5

The US Department of Veterans Affairs (VA) offers IM/CAM health programs to veterans and caregivers as part of its whole health care initiative.6 Several VA health care systems have adopted whole health and IM/CAM through programs for mental health integration into primary care; women’s health; integrative pain care; geriatrics, through adoption of Age-Friendly Health Systems standards; and nutrition and physical activity.7-13 The VA provides training to more medical students than any other health system: > 95% of US medical schools are affiliated with a VA medical center (VAMC).14 As part of the training mission, VA seeks to encourage students of diverse professions to consider careers in the VA.14

Residency is a time for newly licensed physicians to acquire additional experience and training to translate knowledge and skills acquired during medical school directly to patient care.15 However, residency curricula have limited time to incorporate IM/CAM training. Residency training is also physically and psychosocially demanding, often resulting in inadequate self-care, poor work-life balance, and disrupted sleep.16-18 Resident wellness is at a historic low, resulting in high rates of burnout during training.4,15

Residency programs are required to provide wellness education; however, most programs include minimal content.19 Despite high rates of burnout, formal curricula on the topic have not been established. 20 IM/CAM education also can provide a path for residents to learn about and engage in mindfulness-based training or cognitive stress reduction for self-care.

INTEGRATIVE WHOLE HEALTH ROTATION

In 2017, the Baltimore Geriatric Research Education and Clinical Center (GRECC) established an IM/whole health residency rotation and created a structured curriculum incorporating self-assessment, active reflection, and self-care to complement training in specific IM/CAM modalities for residents in family medicine. The curriculum evaluated how this training improved residents’ perceptions of IM/CAM and how it personally and professionally impacted the practice of self-care as a strategy to decrease burnout. We hypothesized that this structured experience would increase IM/CAM knowledge among clinicians while promoting the importance and practice of self-care to reduce burnout.

The 2-week IM/CAM curriculum was developed by University of Maryland School of Medicine faculty in partnership with the Baltimore GRECC and staff at the VA Maryland Health Care System. The curriculum was designed to expose residents to the 8 components of the whole health Circle of Health (moving the body; surroundings; personal development; food and drink; recharge; family, friends, and coworkers; spirit and soul; and power of the mind) in addition to IM/ CAM modalities the VA is mandated to offer to veterans (acupuncture, chiropractic, meditation, massage therapy, biofeedback, clinical hypnosis, guided imagery, yoga, and tai chi).21 Twelve residents (1 preventive medicine and 11 third-year family medicine residents) rotated individually throughout the year as part of their behavioral health block rotation. All residents completed the 2-week curriculum as their schedules allowed. The curriculum consisted of didactics sessions and activities at the Baltimore, Loch Raven, and Perry Point VAMCs. Residents completed evaluations before and after the rotation. The experience described in this article by the residents and the survey data were collected from the 2018/2019 training year. A rotation syllabus, competencies adapted from Locke and colleagues and skills residents obtain during this rotation that support these competencies, as well as a resident sample schedule were developed (eAppendix is available at doi:10.12788/fp.0544).1

FDP042035_App
Rotation Overview

for each resident were built around instructional opportunities, which included 1-on-1 didactics, direct observation of treatment modalities, and personal reflection of the residents’ self-care practices. While each resident’s rotation schedule varied slightly due to their schedules, the foundational instruction elements were the same. Didactic session themes included an overview of IM/CAM, nutrition, narrative medicine, pain psychology, music therapy, chaplain services, motor-cognitive training, and exercise guidelines. Assigned readings, including peer-reviewed literature on IM/CAM therapies, complemented all sessions. Residents created an evidence-supported integrative treatment plan for a patient with a condition of interest to them.

Residents observed clinician-led veteran group sessions on IM/CAM treatment modalities, including guided meditation, mindfulness and relaxation, self-awareness, living well with chronic pain, tai chi, drumming for health and balance, anger management, recovery group, acceptance and commitment therapy, and Gerofit exercise. The group classes allowed residents to actively participate in the activity or discussion. Residents also shadowed VA clinicians in sleep, pain, nutrition, acupuncture, and mental health clinics.

Residents were encouraged to practice self-care during the 2-week rotation. The rotation schedule built in free time, including a 1-hour daily lunch period, for residents to consider their own health habits, complete a personal health inventory, and try self-care activities outlined on the syllabus with links to resources. These resources also served as educational materials that residents could share with patients. All materials, including didactic lectures, journal articles and self-care resources, were provided to each resident through a free online course to ensure residents had access throughout and following completion of the rotation. This content, including the rotation evaluation metrics, is available upon request from the corresponding author.

Evaluations

Residents completed a survey before and after the rotation to measure IM/CAM knowledge and application and self-care/ burnout perceptions. Residents were asked to evaluate rotation sessions and comment on whether this rotation benefited them personally and professionally (Table 1). Descriptive statistics were analyzed using Microsoft Excel. Given the small sample size and lack of statistical power, only mean survey results are reported in this article. Because this opportunity is specific to the University of Maryland School of Medicine and the proposed project was part of ordinary educational practice, the study was deemed not human subject research by the University of Maryland Institutional Review Board (HP-00089256).

FDP042035_T1

Perceptions and attitudes toward IM/CAM were assessed using a survey designed by the University of Minnesota Academic Health Center. It included 18 items scored on a 5-point semantic rating scale (1, strongly disagree; 5, strongly agree).22 Residents rated their level of agreement with statements reflecting both positive (eg, clinical care should integrate the best of conventional and CAM practices) and negative (eg, CAM is a threat to public health) views. Three questions adapted from the NHIS Adult Complementary Health Questionnaire and UC Irvine Survey of Health Care Use and Practice assessed the use of IM/CAM resources.23,24

Resident knowledge and application of IM/CAM were measured using a case study designed by the course faculty. The case listed a chief complaint of nerve pain, with a history of chronic pain, neuropathic pain, anxiety, chronic fatigue, depression, insomnia, posttraumatic stress disorder, history of present illness, past surgical history, medication list, review of symptoms, laboratory values, and physical examination. The residents completed an assessment before and after the rotation. Residents rated their confidence in the diagnosis and treatment of 8 medical conditions using a 5-point semantic rating scale (Table 2). Self-care importance and selfcare frequency were measured by a variety of means, including 3 survey questions, the Five Facet Mindfulness Questionnaire, 2 prompts on a 7-point semantic scale, and a slightly modified version of the validated Perceived Stress Scale.25-28

FDP042035_T2
Survey Results

Residents gave the rotation positive feedback with a mean score of 8.5 out of 10. They reported the beneficial impact of seeing the nontraditional and nonpharmacological practices in treating patients, chronic pain management team approaches, and enjoyed being able to participate in group classes with patients. Many residents expressed a desire for a longer rotation to have more time to experience the behavioral health-focused sessions. Residents also requested additional information on nutritional supplements/natural medicines, battlefield acupuncture training and osteopathic manipulative therapy practices. All residents reported the rotation personally and/or professionally benefited them (Appendix).

Given the sample of 12 residents, values are presented as prerotation to postrotation comparisons without statistical analysis. There was a trend towards an increase in the reported use and recommendation of 26 modalities of nonconventional therapies following the rotation. There was also a slight increase in resource knowledge and use of these resources, and residents reported accessing more types of resources. Mean scores of the case study to gauge knowledge and application of IM increased from 7.5 at baseline to 11.0 after the rotation. Resident confidence in diagnosis increased for all 8 conditions, but confidence in treatment only increased for 4 conditions.

Results of self-care importance, self-care frequency and mindfulness were consistent baseline to postrotation. The mean time residents spent regularly practicing self-care during a work week increased slightly while feelings of burnout decreased. The perceived stress scale average score decreased from 13.4 at baseline to 10.5 after rotation.

DISCUSSION

The implementation of an IM residency rotation that incorporates whole health and interprofessional practices demonstrated improved perception and increased use of IM/CAM resources and knowledge among a small sample of third-year residents. Residents reported they had a positive experience participating in the rotation and gained knowledge, resources, and skills they felt confident discussing with their patients.

Many studies reported favorable attitudes and perceptions of IM/CAM use among physicians, but few have assessed these measures while implementing a training curriculum.3,4,22 Gardiner and colleagues reported on the perception and use of IM resources among family medicine residents.4 The study found that while 58% of all residents reported IM/CAM as an important part of their training, only 60% reported they received it or had specific learning objectives in their curriculum. 4 The program outlined in this study and previous research illustrate that physicians recognize the importance of IM/CAM education in training programs, but most were unaware of the resources available or did not feel comfortable counseling patients about most IM/CAM applications.

Residents in this program slightly increased their use of IM/CAM to diagnose and treat medical conditions after the rotation. A study by Wahner-Roedler and colleagues assessed physician knowledge regarding common IM/CAM therapies.3 On average, physicians only felt knowledgeable and comfortable counseling patients for 3 of 13 listed treatments/techniques and few natural herbal treatments. The study also found that most physicians had difficulty accessing IM/CAM information at their institution despite having free access to electronic databases. However, this study only assessed physician attitudes of IM/CAM and did not include an educational component to increase their knowledge of the modalities.3 This evaluation supports the need for interventions like the program described in this article that provide physicians with access to evidence-based resources combined with the applied experiences to increase their comfort within this growing field.

Though the sample size in this study was small, its results support existing research indicating that clinicians view selfcare as important. Many residents were already using a self-care plan at baseline, but there was slight increase in the practice of self-care during the rotation and a slight decrease in burnout. Previous research reflects high rates of burnout and relatively poor quality of life among primary care physicians.15 Burnout is associated with lower quality of care, lower patient satisfaction and contributes to medical errors. Studies suggest as many as 60% of primary care physicians report symptoms of burnout, which negatively affected the quality of patient care they provide.15

Despite the profound effects burnout has on physicians and patient care, a standardized wellness education or self-care tool kit is not currently available. The University of Massachusetts recently introduced a pilot program to promote resident wellness that demonstrated favorable results.15 A meta-analysis of physicians and medical trainees found decreases in anxiety and symptoms of anxiety as well as a decrease in burnout among participants in cognitive, behavioral and mindfulness interventions.29 However, unlike our program, these programs focused solely on the well-being of medical trainees, residents, and physicians and didn’t focus on the patient-clinician interactions. Given the impact on patient care, there is a need to develop and implement additional programs like our residency rotation that promote health and wellness among physicians while also evaluating how physicians may translate these skills to patient education.

While this program st i l l exists for third-year residents at Baltimore GRECC, it has significantly changed since the COVID-19 pandemic. For about the first 6 months of the pandemic, when physical distancing requirements were in place, family medicine trainees were not able to rotate. Upon return to the facility, many group classes were cancelled and some clinicians no longer offered the sessions. The rotation has evolved to a hybrid format, where many group classes for veteran patients are offered virtually, and residents observe a mix of virtual and in-person shadowing opportunities. Our formal evaluation included administering the survey and occurred from July 2018 to July 2019 but wasn’t implemented upon return to post-COVID activities due to the inconsistent experiences offered to residents over the past few years. Future research should evaluate the impact of this hybrid program on the clinicians and explore dissemination to other VAMCs and their academic affiliates.

Limitations

Project recruitment was limited to 11 family medicine and 1 preventive medicine resident. Perceptions, use of IM/CAM, and knowledge about IM/CAM could be considerably different in different departments with varying schedules, hours worked, and patient volumes. Secondly, the survey was conducted 2 weeks apart. Indications of self-care and burnout may not reflect long-term effects, adoption, or maintenance. Future research should include longer follow up to examine how this type of educational activity may impact burnout rates of physicians following the completion of residency, as well as changes in perspectives of IM/CAM while practicing as a physician. Trainees were exposed to a wide range of health care professions, but additional research is needed regarding medical resident perceptions of the roles of specific professions in a collaborative health care team.30,31

CONCLUSIONS

The residency rotation program illustrates the benefits of establishing a standardized IM/CAM rotation that includes self-care resources in family medicine programs to adequately train clinicians to practice wellness and promote it to their patients. The results of this project suggest this type of training will help residents assess the literature to better counsel patients on IM/CAM options while also providing strategies for maintaining optimal health and well-being for health care professionals. Broadening and shifting the scope of medicine from treatment to prevention, personal wellness, and optimal healing should be a top priority.

References
  1. Locke AB, Gordon A, Guerrera MP, Gardiner P, Lebensohn P. Recommended integrative medicine competencies for family medicine residents. Explore (NY). 2013;9(5):308-313. doi:10.1016/j.explore.2013.06.005
  2. Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. JAMA. 1998;280(18):1569-1575. doi:10.1001/jama.280.18.1569
  3. Wahner-Roedler DL, Vincent A, Elkin PL, Loehrer LL, Cha SS, Bauer BA. Physicians’ attitudes toward complementary and alternative medicine and their knowledge of specific therapies: a survey at an academic medical center. Evid Based Complement Alternat Med. 2006;3(4):495-501. doi:10.1093/ecam/nel036
  4. Gardiner P, Filippelli AC, Lebensohn P, Bonakdar R. Family medicine residency program directors attitudes and knowledge of family medicine CAM competencies. Explore (NY). 2013;9(5):299-307. doi:10.1016/j.explore.2013.06.002
  5. Sierpina V, Levine R, Astin J, Tan A. Use of mind-body therapies in psychiatry and family medicine faculty and residents: attitudes, barriers, and gender differences. Explore (NY). 2007;3(2):129-135. doi:10.1016/j.explore.2006.12.001
  6. Krist AH, South-Paul J, Meisnere M, eds. Achieving Whole Health: A New Approach for Veterans and the Nation. The National Academies Press; 2023.
  7. Bokhour BG, DeFaccio R, Gaj L, et al. Changes in patientreported outcomes associated with receiving whole health in the Veteran Health Administration (VHA)’s National Demonstration Project. J Gen Intern Med. 2024;39(1):84-94. doi:10.1007/s11606-023-08376-0
  8. Courtney RE, Schadegg MJ, Bolton R, Smith S, Harden SM. Using a whole health approach to build biopsychosocial- spiritual personal health plans for veterans with chronic pain. Pain Manag Nurs. 2024;25(1):69-74. doi:10.1016/j.pmn.2023.09.010
  9. Gabrielian S, Jones AL, Hoge AE, et al. Enhancing primary care experiences for homeless patients with serious mental illness: results from a national survey. J Prim Care Community Health. 2021;12:2150132721993654. doi:10.1177/2150132721993654
  10. Matthieu MM, Church KA, Taylor LD, et al. Integrating the age-friendly health systems movement in Veterans Health Administration: national advance care planning via group visits and the 4Ms framework. Health Soc Work. 2023;48(4):277-280. doi:10.1093/hsw/hlad022
  11. Meisler AW, Gianoli MO, Na PJ, Pietrzak RH. Functional disability in US military veterans: the importance of integrated whole health initiatives. Prim Care Companion CNS Disord. 2023;25(4):22m03461. doi:10.4088/PCC.22m03461
  12. Ortmeyer HK, Giffuni J, Etchberger D, Katzel L. The role of companion dogs in the VA Maryland Health Care System Whole Health(y) GeroFit Program. Animals (Basel). 2023;13(19):3047. doi:10.3390/ani13193047
  13. Sullivan MB, Hill K, Ballengee LA, et al. Remotely delivered psychologically informed mindful movement physical therapy for pain care: a framework for operationalization. Glob Adv Integr Med Health. 2023;12:27536130231209751. doi:10.1177/27536130231209751
  14. (OAA) OoAA. 75th Anniversary: Passion to learn. Power to heal. Washington DC.: US Department of Veterans Affairs; 2021. https://content.yudu.com/web/448fx/0A448g9/75thAnniversary2021/html/index.html?page=24&origin=reader
  15. Runyan C, Savageau JA, Potts S, Weinreb L. Impact of a family medicine resident wellness curriculum: a feasibility study. Med Educ Online. 2016;21:30648. doi:10.3402/meo.v21.30648
  16. Lafreniere JP, Rios R, Packer H, Ghazarian S, Wright SM, Levine RB. Burned out at the bedside: patient perceptions of physician burnout in an internal medicine resident continuity clinic. J Gen Intern Med. 2016;31(2):203-208. doi:10.1007/s11606-015-3503-3
  17. Freedy JR, Staley C, Mims LD, et al. Social, individual, and environmental characteristics of family medicine resident burnout: a CERA study. Fam Med. 2022;54(4):270-276. doi:10.22454/FamMed.2022.526799
  18. Alrishan MA, Alshammari SA. Prevalence of sleep deprivation and its effect on the performance of family medicine residents in Riyadh, Saudi Arabia. J Family Community Med. 2020;27(2):125-130. doi:10.4103/jfcm.JFCM_9_20
  19. ACGME. ACGME Program Requirements for Graduate Medical Education in Family Medicine. https://www.acgme.org/globalassets/pfassets/programrequirements/120_familymedicine_2024.pdf
  20. Nene Y, Tadi P. Resident Burnout. In: StatPearls; 2023.
  21. Bokhour BG, Haun JN, Hyde J, Charns M, Kligler B. Transforming the veterans affairs to a whole health system of care: time for action and research. Med Care. 2020;58(4):295-300. doi:10.1097/MLF.0000000000001316
  22. Kreitzer MJ, Mitten D, Harris I, Shandeling J. Attitudes toward CAM among medical, nursing, and pharmacy faculty and students: a comparative analysis. Altern Ther Health Med. 2002;8(6):44-53.
  23. Clarke TC, Black LI, Stussman BJ, Barnes PM, Nahin RL. Trends in the use of complementary health approaches among adults: United States, 2002-2012. Natl Health Stat Report. 2015(79):1-16.
  24. Nguyen J, Liu MA, Patel RJ, Tahara K, Nguyen AL. Use and interest in complementary and alternative medicine among college students seeking healthcare at a university campus student health center. Complement Ther Clin Pract. 2016;24:103-108. doi:10.1016/j.ctcp.2016.06.001
  25. Baer RA, Smith GT, Hopkins J, Krietemeyer J, Toney L. Using self-report assessment methods to explore facets of mindfulness. Assessment. 2006;13(1):27-45. doi:10.1177/1073191105283504
  26. Baer RA, Smith GT, Lykins E, et al. Construct validity of the five facet mindfulness questionnaire in meditating and nonmeditating samples. Assessment. 2008;15(3):329-342. doi:10.1177/1073191107313003
  27. West CP, Dyrbye LN, Sloan JA, Shanafelt TD. Single item measures of emotional exhaustion and depersonalization are useful for assessing burnout in medical professionals. J Gen Intern Med. 2009;24(12):1318- 1321. doi:10.1007/s11606-009-1129-z
  28. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983;24(4):385-396.
  29. Regehr C, Glancy D, Pitts A, LeBlanc VR. Interventions to reduce the consequences of stress in physicians: a review and meta-analysis. J Nerv Ment Dis. 2014;202(5):353-359. doi:10.1097/NMD.0000000000000130
  30. Visser CLF, Ket JCF, Croiset G, Kusurkar RA. Perceptions of residents, medical and nursing students about interprofessional education: a systematic review of the quantitative and qualitative literature. BMC Med Educ. 2017;17(1):77. doi:10.1186/s12909-017-0909-0
  31. Lingard L, Espin S, Evans C, Hawryluck L. The rules of the game: interprofessional collaboration on the intensive care unit team. Crit Care. 2004;8(6):R403-408. doi:10.1186/cc2958
References
  1. Locke AB, Gordon A, Guerrera MP, Gardiner P, Lebensohn P. Recommended integrative medicine competencies for family medicine residents. Explore (NY). 2013;9(5):308-313. doi:10.1016/j.explore.2013.06.005
  2. Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. JAMA. 1998;280(18):1569-1575. doi:10.1001/jama.280.18.1569
  3. Wahner-Roedler DL, Vincent A, Elkin PL, Loehrer LL, Cha SS, Bauer BA. Physicians’ attitudes toward complementary and alternative medicine and their knowledge of specific therapies: a survey at an academic medical center. Evid Based Complement Alternat Med. 2006;3(4):495-501. doi:10.1093/ecam/nel036
  4. Gardiner P, Filippelli AC, Lebensohn P, Bonakdar R. Family medicine residency program directors attitudes and knowledge of family medicine CAM competencies. Explore (NY). 2013;9(5):299-307. doi:10.1016/j.explore.2013.06.002
  5. Sierpina V, Levine R, Astin J, Tan A. Use of mind-body therapies in psychiatry and family medicine faculty and residents: attitudes, barriers, and gender differences. Explore (NY). 2007;3(2):129-135. doi:10.1016/j.explore.2006.12.001
  6. Krist AH, South-Paul J, Meisnere M, eds. Achieving Whole Health: A New Approach for Veterans and the Nation. The National Academies Press; 2023.
  7. Bokhour BG, DeFaccio R, Gaj L, et al. Changes in patientreported outcomes associated with receiving whole health in the Veteran Health Administration (VHA)’s National Demonstration Project. J Gen Intern Med. 2024;39(1):84-94. doi:10.1007/s11606-023-08376-0
  8. Courtney RE, Schadegg MJ, Bolton R, Smith S, Harden SM. Using a whole health approach to build biopsychosocial- spiritual personal health plans for veterans with chronic pain. Pain Manag Nurs. 2024;25(1):69-74. doi:10.1016/j.pmn.2023.09.010
  9. Gabrielian S, Jones AL, Hoge AE, et al. Enhancing primary care experiences for homeless patients with serious mental illness: results from a national survey. J Prim Care Community Health. 2021;12:2150132721993654. doi:10.1177/2150132721993654
  10. Matthieu MM, Church KA, Taylor LD, et al. Integrating the age-friendly health systems movement in Veterans Health Administration: national advance care planning via group visits and the 4Ms framework. Health Soc Work. 2023;48(4):277-280. doi:10.1093/hsw/hlad022
  11. Meisler AW, Gianoli MO, Na PJ, Pietrzak RH. Functional disability in US military veterans: the importance of integrated whole health initiatives. Prim Care Companion CNS Disord. 2023;25(4):22m03461. doi:10.4088/PCC.22m03461
  12. Ortmeyer HK, Giffuni J, Etchberger D, Katzel L. The role of companion dogs in the VA Maryland Health Care System Whole Health(y) GeroFit Program. Animals (Basel). 2023;13(19):3047. doi:10.3390/ani13193047
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Development of an Integrative Medicine Rotation for Family Medicine and Preventive Medicine Residency

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Development of an Integrative Medicine Rotation for Family Medicine and Preventive Medicine Residency

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