Incorporating a Web-based, Integrative Medicine Curriculum into 8 Family Medicine Residencies: Keys to Success

Victoria Maizes, M.D., Victor Sierpina, M.D., John Woytowicz, M.D., Selma Sroka, M.D., Sally Dodds, Ph.D., & Patricia Lebensohn, M.D.

Presentation Objectives• The objectives of this presentation are:

▫ Recognize the steps in creating competency-based education including the evaluation methodology.

▫ Understand program strategies used in incorporating a new curriculum into existing residency training.

▫ Review key outcomes of courses completed and change in IMR medical knowledge.

▫ Review individual program successes and challenges in implementation methodology.

Integrative Medicine in Residency (IMR) is…

• Competency-based, online, 200-hour, curriculum.• In-depth training in Integrative Medicine.• Incorporated through all 3 years of Family Medicine

residency.• Piloted at 8 residencies nationwide.• Seamless, online evaluation of the curriculum and the

residents.• Responds to ACGME competency requirements.• Evaluation developed simultaneously with the

curriculum.

University of Arizona

University of Texas Medical Branch

Hennepin County

Carolinas Medical Center

Beth Israel

Maine-DartmouthMaine Medical

CenterUniversity of Connecticut

IMR Program Locations

Moses H. Cone

Alaska Family Medicine

Univ. of Minn

A. Einstein Montefiore

Control sites

Tools in Integrative Medicine

Prevention and

Wellness

Women’s Health

Chronic Illness

Pediatrics

Acute Care

IMR Curriculum Units

Introduction to Integrative MedicinePrevention and Wellness:• U.S. Preventive Health Services• Nutrition and Diet • Supplements for Prevention• Physical Activity• Sleep • Stress and Mind-Body Medicine • Spirituality• Clinical Integration

Tools in Integrative Medicine:• Integrative Medicine Intake and Care Plan • Botanicals• Mind-Body Medicine• Manual Medicine • Introduction to Energy Medicine and Whole

Systems • Practice Management• Motivational Interviewing for Behavioral

Change

Acute Care:• Acute Back Pain,• Urinary Tract Infection,• Gastroenteritis,• Otitis Media,• Vaginitis,• Atypical Chest Pain,• Upper Respiratory Infection

Pediatric Topics:• ADD/ADHD• Chronic Pain Syndrome• Asthma and Allergies

Women’s Health Topics:• PMS/PMDD• Dysmenorrhea• Menopause• Fibromyalgia• Osteoporosis • Depression • Eating Disorders • Pregnancy and Lactation

Chronic Illness: • Cardiovascular Disease• Type II Diabetes• Osteoarthritis • Rheumatoid Arthritis• Obesity • Irritable Bowel Syndrome• Chronic Back Pain

Special Topics:• HIV/AIDS • Cancer Survivorship• Environmental Medicine

Units and Courses

IMR: Educational Methods Needs assessment informed curriculum design. Web-based curriculum written and edited by Integrative

Medicine educators. Competencies aligned with the ACGME Outcomes

Project. Flexible modular format to meet the needs of residency

schedules. Case-based, interactive learning and streaming video. Experiential exercises and process-oriented group

activities at the residency sites. A community of learners through online dialogues with

faculty and peers. Emphasis on teaching and promoting physician well-

being and self-care.

IMR User Interface

Online portfolios

Flexible modular format

Resources and Links

Direct Observation Checklists

Reflections

What is Evaluated in the IMR?• Curriculum:

▫ Residents evaluate each course after completion• Residents’ competencies:

▫ Medical Knowledge test▫ Self Assessment▫ Direct Observation Checklist▫ Reflections

• Residents’ wellness & well-being:▫ Behavioral assessments

• Residency recruitment:▫ Match results and post match survey

As of March 19, 2010

Yr 01 Course CompletionsClasses of 2011 and 2012

Intro

Preve

ntion

Nut. & D

iet

Supplem

ents

Phys. A

ctivit

ySlee

p

Spiritu

ality

Stress

& M

-B

Clinica

l Integ

100% 99% 94% 92% 92% 90% 90% 90% 88%85%72%

56%44%

50%41% 41% 40%

29%

2011 2012

As of March 19, 2010

Yr 02 Course CompletionsClass of 2011

IM In

take

Mot Int

v

Botanic

M-B Pra

ct

Acute

care

Pediat

rics

ADHD

Ped A

llerg

yPain

Women

PMD/PMDD

Dysmen

Pregn

ancy

Eating

Dis

Fibrom

y

Depre

ssion

Women

ICS

Menop

Osteop

or0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

23%18%18%15%

37%

64%

44%

55%

38%

62%54%

48%40%38%34%

28%29%32%29%

Clinical Utility of the Course?Year 01 Content

*Currently, indicators are available for 4 courses for the 2012 class.

Meet Learning Objectives? Clinical Utility?

Year 02 Course EvaluationsCourses currently at 50% threshold

Year 02 Course EvaluationsCourses currently at 50% threshold

Smooth Online technology?

2011 (58) 2012 (62) Controls (27)

48.7% 51.4% 54.1%

Yr. 01

Medical Knowledge TestMean percent correct at baseline – All groups

ns

Medical Knowledge TestSub group differences at baseline – Class of 2011

Sex Medical School Status

Se-ries1

0.526

p = .007

Males Females

Series1

53.9% 55.7%

33.5%

p . < .001

US - MD US - DO FMG

Series1

48.8%57.8%

Baseline 1st Post-test

Medical Knowledge TestPre-/Post Test Class of 2011 – Yr. 01

2011 2012 2013

51%

41%

58%

44% 42% 45%

18%26%

17%

27% 28% 26%

4% 5%0%

US MD National US DO FMG Unk

Post Match1Match Results 2011, 2012, 2013

Post Match2IM/CAM Medical School Courses &Personal Use

Controls rated higher than 2012 group on all questions.

* 2011 more required IM/CAM courses in medical school than 2012 (p<.001).

* 2011 more electives in medical school than 2012 (p<.001).

* Controls more electives than 2012 (p=.012).

* 2011 more personal IM/CAM use than the 2012 group (p=.014).

Required course

Elective Personal use

75%

63%67%

35%

21%

42%

57%50% 53%

2011 2012 Controls

2011 (n=57)2012 (n=43)Control(n=30)

Post Match3Interest in Learning IM in Residency

High interest in both the 2011 and 2012 groups.•But, over half of the controls also had high interest.

* 2011 group had a higher interest than controls (p=.002).

High/Mod-erate

Neutral Some/Not at all

0.88

0.12

77%

7%

25%

60%

23%17%

2011 2012 Controls

2011 (n=57)2012 (n=43)Control(n=30)

Post Match4Importance of the IMR in Ranking Decision

Very important/Important:•2011 – 53%•2012 – 37%

Notes:1. Likert scale revised to 5 points and

accounts for differences in scores.2. 2011 totals >100%– rounding error .

High/M

oder

ate

Impo

rtant

Neutra

l

Somew

hat

Not Im

port

28% 25%21%

27%

14%

23%28%

14%21%

2011 2012

2011 (n=57)2012 (n=43)

Post Match5Interest in Applying IM in PracticeHigh to moderate interest in both the 2011 and 2012 groups.•Controls also had high to moderate interest.

* 2011 group had higher interest in applying IM in practice than controls (p=.001).

Notes:1. 2011 totals more than 100%– rounding error

High/Moderate Neutral Some/None

0.9

0.11

77%

5%

19%

57%

23% 20%

2011 2012 Controls

2011 (n=57)2012 (n=43)Control (n=30)

Implementation Strategies

Individual activities: • Free blocks of time longitudinally• Use concentrated time in certain rotations (orientation, community

medicine, integrative medicine, nursery). • Do content matched with rotations (e.g., outpatient pediatrics,

maternal child health, GYN, EM)

Group activities: • Wellness and self care• Videos• Motivational interviewing• Mind-Body skills training• Integration with behavioral

health program

• Field trips• Yoga, tai chi• OMT skills• Nutrition lecture series• Integrative approach to

lecture topics

Implementation Challenges

• Finding the time in the curriculum.• Motivating some residents to keep on track and progress

through the curriculum.• Getting faculty interested in participating in the

curriculum.• Incorporating an Integrative Medicine approach into

busy outpatient care sessions.

Implementation Successes

• Most residents are progressing well through the curriculum.• Evaluations are very encouraging.• One sites from the 2011 class is requesting continued access

to the curriculum after graduation.• The presence of the IMR attracts competitive residents to the

pilot sites.• Residents’ medical knowledge has increased from Yr. 01 to Yr.

o2.

• Unknown:• Residents’ well-being• Patient centeredness• Patient outcomes• Practice patterns after graduation

Next Steps• Complete the Yr. 03 content • Analyze Behavioral Assessments/residents’ well-being and

compare with control groups• Expand to other programs

• 5 early adopters in 2010• Medical Center of Central Georgia, Macon, GA• Tufts University Family Medicine, Malden, MA• Aurora Family Medicine Residency Program, Milwaukee, WI;

Research Family Medicine, Kansas City, MO;• Internal Medicine Residency University of New Mexico,

Albuquerque NM.• Build a stand alone course on Prevention and Wellness for

residents and medical students

DiscussionAcknowledgements

University of Arizona Pilot Sites

Emily Sherbrooke Mary Guerrera, M.D.

Paula Cook Ben Kligler, M.D., MPH

Rhonda Hallquist Craig Schneider, M.D.

Tieraona Low Dog, M.D. Raymond Teets, M.D.

Dael Waxman, M.D.

Teaching Strategies

Site Course Teaching Strategy Examples

U of A Physical ActivitySupplements

Yoga classVisit to health food store w/ cases & budget

Maine MC SupplementsNutrition

Visit to traditional herbalist storeTrip to chicken processing plant

U Conn Nutrition Lecture with sampling of various foods

Beth Israel

Nutrition Evening dinner discussion

Hennepin Stress and M-B Experience in PMR, hypnosis, breath work

Carolinas Physical ActivityStress and M-B

Ropes course w/ faculty during orientationMindfulness meditation sessions

U Texas Stress and M-B Lecture and acupuncture experience

Maine Gen

Clinical Integration

Patient joins the IMR case staffing