Integrative Medicine in Residency Successes and Challenges in

Integrative Medicine in Residency Successes and Challenges in Developing & Implementing a Comprehensive Research-Driven Curriculum in Residency Education NARCCIM 2009

Objectives Learn about the research processes to develop a competency based curriculum in Integrative Medicine Identify the findings of the needs assessment survey at participating residencies Describe the competencies and curriculum components Learn about the evaluation plan and baseline assessment results Discuss challenges and successes of implementation

What is the Integrative Medicine in Residency Program? 200 -hour online curriculum developed by University of Arizona Center for Integrative Medicine Pilot Partners: 8 family medicine residencies Purpose: Create and deliver competency-based online integrative medical training to residents Goal: Expand to other primary care and subspecialty training programs

IMR Program Locations Maine-Dartmouth Maine Medical Center Hennepin County University of Connecticut Beth Israel Carolinas Medical Center University of Arizona University of Texas Medical Branch

Unique Features of IMR Competency-based, based on ACGME outcome project Needs Assessment driven process Web-based and on-site small group activities Common curriculum for multiple residencies Modular format allows maximum flexibility Capacity to create a community of learners beyond the individual residency programs Built-in evaluation

Needs Assessment Survey • Key content areas • Preferences for Length • Format • Perceptions of IM • Curriculum Challenges

Sample Characteristics No IM Exposure

Top IM Content Areas Needed to Enhance Curriculum

Comments Related to Curriculum Inclusion by Them Centrality of Curricular Focus Value to the Profession

Challenges for Integrating IM Content into Curriculum

IM Competencies Rationale for IM competency base • ACGME outcome project set domains for GME. Guide the learning objectives and determine outcomes to be evaluated. Process for IM competency development • Initial draft after literature review and ACGME defined domains • Used consensus process to arrive at 27 competencies • Selected via nominal consensus process 14 competencies to direct learning objectives and evaluation process * STFM group on IM reviewed the competencies to forward to the FM RRC to include language in requirements

Year 1 Content Foundations of IM US Preventive Guidelines Nutrition and Diet Supplements Physical Activity Stress and Mind-Body Sleep and Health Spirituality in Health Care Clinical Integration Motivational Interviewing

Years 2 and 3 Content Year 2 Pediatric Topics Women’s Health Acute Care Botanicals Mind-Body Medicine IM intake Year 3 Chronic Illness Special Topics Manual medicine Whole systems IM treatment plans Practice Management

IMR Class Page

Evaluation of IMR Success Outcome Level Educational Proficiency Curriculum Design Program IM Competency Learner Satisfaction & Ease Enhanced Resident Recruitment Resident Well-being Multi-method Approach • • • Quantitative and Qualitative Mix of standardized and customized tools Observations, surveys, tests, portfolio

Major Evaluation Design Challenges Blending research design with applied curricular evaluation • Rigor vs. Reality Designing competency assessment process • Following ACGME outcome project recommendations • Review results: lack of reliability and consistency of measures and processes Developing new measures and methods • Self-Assessment, Observation, MC Tests, Reflective Questions, Portfolio • Feasibility in design and/of implementation • Standardization of use by faculty and time frame

Competency Measurement ACGME 1. Patient Care Measures Multiple Direct Observations Time Points Several at Years 1 & 3 2. Medical Knowledge MC Tests Yearly 3. Interpersonal Skills 4. Professionalism 5. Systems Practice Multiple Direct Observations Self-Assessment Reflections, Products Years 1 & 3 6. Practice Base Self-Assessment Yearly Years 2 & 3

Tracking of IMR Evaluation: The Portfolio

IMR & Site Program Evaluation Measures Enhanced Residency Recruitment Surveys to program director to assess ratings of resident Candidate and match Success Slots taken Incoming resident survey to assess IM interest and residency program attraction Resident Well-Being Standardized Scales of Depression, Burn-out, Stress, Anxiety, Stress, Satisfaction with Life

Baseline Findings: Self-Assessment of IM Knowledge/Skills (n=65) Least Adequate Most Adequate Prescribing different mind-body stress techniques (2. 06) Supplements for prevention of specific conditions (2. 21) Fundamental tenets of Integrative Medicine (2. 30) Gender/age specific vitamin supplements (2. 32) Physical activity recommendations for different populations (2. 70) Able to balance my work and personal life (2. 78) Clinical implications of acute & chronic stress (2. 79) Comfort discussing spirituality with patients (2. 84) Nutritional needs of different populations for health promotion and disease prevention (2. 40) Practicing self-reflection on a regular basis (2. 92)

Self-Assessment: Major Themes (n=228)

Self-Assessment: IM Sub-Themes

IM Medical Knowledge Percent Correct by Site N=65 15 multiple choice questions

Year 1 Completion Status April 2009

IMR Year 1 Course Evaluation by Residents

Time to Complete Courses (self-report) Time to Complete Y 1 Curriculum Minimum Time = 3. 5 hours Maximum Time = 36 hours Average Time = 13. 5 hours

IM Interest by Residents Entering Pilot Programs in 2008

Program Site Perspective: IMR Challenges • Faculty labor/time limits • Resident time limits • Faculty buy-in • Faculty development • Need for IM trained faculty • Time to complete direct observations • Limited resident interaction • IMGs somewhat “risk averse”

Program Perspective: IMR Successes • Residents are excited, participating, and giving • • • excellent feedback Online community is a good way to connect residents Monthly integrative medicine case conference Residents are completing content as expected Residents are using medical knowledge and skills learned in the outpatient setting Faculty impressed by selection and IMR impact

Strategies to Engage Online Learning • FOOD---Internship dinner • Introducing IMR during orientation • Identify for residents time periods where they can • • • complete curriculum Completing course as a group in computer lab Monthly sessions/small group activities on IM topics Wellness session with residents and faculty • Regular email contact with residents • Thank–you email when residents complete courses • Tip of the month/article with link to the curriculum

Questions and Conclusions