Edward Mills DPH, MSc, PhD Cand. (1) Kumanan Wilson MD, MSc, FRCP(C) (2) Cory Ross DPH, DC, MSc, FRSH (1) Nick DeGroot ND (1)

(1)Canadian College of Naturopathic Medicine
(2)Department of Medicine, University of Toronto

Correspondence: Edward Mills, Department of Research, Canadian College of Naturopathic Medicine, 1255 Sheppard Ave. East, North York, Ontario, Canada, M2K 1E2

Abstract

Developing and evidence-based clinical approach to complementary and alternative medicine (CAM) is seen by many as an essential step to the further development of the discipline.  To develop such an approach will require effective integration of evidence-based complementary and alternative medicine (EBCAM) teaching into current academic programs.  Present research suggests that introducing evidence-based approaches later in CAM curricula may not be successful.  This paper describes an alternative approach in which CAM instructors model the use of evidence-based CAM to their students, beginning at an early stage in their education, thereby more effectively communicating its importance and value.  For such mentoring and modelling approaches to work will also require that the instructors maintain an open dialogue with their students and are responsive to their concerns and feedback.

Introduction: Observations of the current CAM education have suggested the necessity of creating an academic environment with “an obsession with finding, appraising and using research-based knowledge in decision making” [1]. Successful educational interventions of a single type have limitations [2] as learning styles differ amongst the target population.  A multifactorial approach with administrative support is likely to impact long-term knowledge upon CAM students and therapists.   In doing so, participation should happen on many levels, from administrative to mentorship and student opinion leaders.  Theoretical learning and didactic approaches have value in supplying equal learning to all of the students, yet as clinicians are developed and clinical decision making becomes refined, the student should observe the value of critical thinking and self-assessment.

Adult learning theories address the issue that if behavioural change is to occur, the student should experience the value of the new information.   Medical education extends over the lifetime of the individual, as medical information improvesevolves.  Thus, building self-directed learners should be a focus of educational organisations [3].  CAM therapists should be self-directed in their learning activities and be able to relate new information to their own needs and experiences. For this reason, theories of adult learning that emphasise personal direction and experiential learning are highly valuable.

Displaying evidence-based complementary and alternative medicine (EBCAM) as a valuable tool to increase knowledge of the individual and acceptance of the CAM professions within healthcare is a challenge to an academic institution, as many CAM therapists have a vested interest (whether financial, historical or spiritual) in believing adhering to what has been previouslypreviously  learned about traditional practices.  To begin evidence-based (EB) approaches late in the curriculum, with the possibility of disproving previously accepted theories, can create a feeling of discontent with studies [4]. Thus, EBCAM should be implemented at an early stage and allow students to observe the benefits through modelling.

 

 

Table 1, Adult learning makes the following assumptions about the design of learning:

(1) need to know why they need to learn something

(2) need to observe and  experience,

(3) approach learning as problem-solving,

(4) learn best when the topic is of immediate value.

 

Modelling

The term modelling refers to the concept of observing [and replicating] the behaviours, attitudes and emotional reactions of others.  Most human behaviour is learned through modelling: “from observing others, one forms an idea of how new behaviours are performed, and on later occasions this coded information serves as a guide for action”[5].

Table 2. Principles of Social Learning Theory  [6].

1. The highest level of observational learning is achieved by first organizing and rehearsing the modelled behaviour symbolically and then enacting it overtly. Coding modelled behaviour into words, labels or images results in better retention than simply observing.

2. Individuals are more likely to adopt a modelled behaviour if it results in outcomes they value.

3. Individuals are more likely to adopt a modelled behaviour if the model is similar to the observer and has admired status and the behaviour has functional value.

Modelling encompasses attention, memory and motivation, thus spans both cognitive and behavioural frameworks of learning [7]. As the CAM student or practitioner ponders the relevance of EBCAM, expected reticence may be displaced by the observation of colleagues and opinion leaders use of an evidence-based method.  Modelling addresses the needs and wants of the learner, incorporating personal involvement with respected opinion [5]. If we agree that all human beings have a natural propensity to learn, then the teacher should facilitate this through: creating a positive climate, making available the resources to learn (internet, CD-Roms), balancing intellectual and emotional components of learning, and sharing thoughts with the learner [8].

Table 3. Principles of Experiential Learning [8].

1. Significant learning takes place when the subject matter is relevant to the personal interests of the student

2. Learning which is threatening to the self (e.g., new attitudes or perspectives) are more easily assimilated when external threats are at a minimum

3. Learning proceeds faster when the threat to the self is low

4. Self-initiated learning is the most lasting and pervasive.

 

Successful educational experiences involve communication with learned colleagues and, at times, not so learned colleagues.  Many of us in an academic administrative roles can remember the benefit and impact of timely attention and counsel of someone in a position of authority or specialised knowledge; a person who listened to our concerns, provided appropriate advice and made our passage through the caverns of medical education less hazardous and more personally rewarding [9]. A successful modeller or mentor characteristically embodies the qualities sought by the adult learner: intelligence, empathy, and clinical experience [9,10].  That search for guided learning seems a useful metaphor in understanding the attributes of successful mentorship in a CAM educational setting.

Regarding intelligence, mentorship not only provides a transfer of knowledge, but demonstrates how to acquire and apply the critical thinking skills and the habits of enquiry and logical argument needed to create and communicate increased knowledge. Similarly, successful mentorship requires empathy, expressed in the responsiveness and understanding by which good mentors forge relationships of trust with students who often are struggling with personal difficulties or problems in adapting to the particular culture of the institution [9].

That quality of caring in mentoring relationships is also the foundation for the specialized insights and positive reinforcement which increase and reward intellectual curiosity and make students value education not only for its utility, but for the satisfactions of learning. Good mentorship fosters students’ personal growth and self-reliance through faith in reasoned viewpoints and confidence in acting, as the Oxford English dictionary calls it, “on one’s beliefs and convictions” [11].  In part, the reason that EB practice is so important an orientation to instil is that less of the body of CAM ‘knowledge’ is practiced with citable evidence that the authors would prefer.

The skills and attributes required for good mentorship are the skills and attributes we wish to instil in our students. Of course, mentoring abilities are not an artefact of birth and their development requires nurturing resources, training, and conscious effort within a supportive institutional setting (See Figure 1).

Figure 1. Evidence-Based Organisations [1]. 

But even if all of these elements are present, and discounting for the pressures of time and functionally-specific institutional roles, not all teachers will make good mentors. Their aptitude for mentorship resides in their individual characteristics and experience. Thus, one of the important products of mentoring relationships is that successful students are encouraged to themselves become mentors, to expand their skills and develop their characters, and to transfer that positive experience to successive generations.  The use of opinion leaders in every tier of the academic setting formulates the institutional atmosphere and thus the development of andragogical (adult-learning) learning (See Table 3).

The Role of Democracy in Education

Table 4. Principles of Andragogy [12,13]

1. Adults need to be involved in the planning and evaluation of their instruction.

2. Experience (including mistakes) provides the basis for learning activities.

3. Adults are most interested in learning subjects that have immediate relevance to their job or personal life.

4. Adult learning is problem-centered rather than content-oriented.

Evidence-Based Medicine approached the new millennium reeling from the transformative socio-economic impacts of rapid globalisation, taking a lead role  on new technologies, and the advent of the “information economy”[14], and fundamental questions about the role of the “expert” [15]. The scope and speed of these changes has produced widespread uncertainty and anxiety and thus, it would be surprising if the goals and methods of education were not subjects of increased controversy [16].  Just as medicine changes, so too must medical education.

While educators, policymakers, and important attentive publics (students, patients, taxpayers, employers, social activists and advocates, etc.) seem agreed on the need to reform the medical educational system, in the resulting competition for influence and resources there seems little basis for consensus as to what needs changing or how that might be done.

For instance, there are those who believe that the salient problem is “content-delivery”  and that its resolution can be found in better instruction, perhaps through greater reliance on computer-based technologies. There are those who believe that to improve education requires primary emphasis on better curricular “content,” typically through renewed and rigorous attention to the traditional basic sciences [10]. Yet we would argue that an emphasis on theoretical thinking and the inclusion of philosophy, ethics, logic and languages may help develop the clinician understand values; whether patient’s, profession’s or personal.

Of course, those views are not mutually exclusive; nor are they adequate representations of the range of informed viewpoints on the subject, and judging the merits of either of these approaches or assessing their applicability to CAM education is beyond the scope of this essay. However, it is arguable that much of the continuing search for “creative” means to better deliver and improve course content has been at the expense of actually talking with students, and that good education requires individual faculty and students to be continuously engaged in dialog which promotes learning [3]. As the experience of CAM education, whatever its other flaws and strengths, becomes more impersonal (crowded classrooms, computer-based instruction, independent study courses, etc.), the role of mentoring and modelling becomes more significant.

Fostering the Democratic Environment

Schools which recognize the importance of modelling and mentorship may promote the learning through building institutional supports and enhancing the capabilities of individual faculty.  Both of these require resources, purposeful effort, leadership and resolve. They include emphasizing teaching and interpersonal skills in recruitment and promotion, developing specialized in-service training in better teaching and counselling, providing all faculty (not only academic advisors and counsellors) with the time and suitable physical facilities to see students, developing intervention mechanisms and referral destinations for students in difficulty, and even the use of retired and part-time faculty as advisors. All these activities promote mentorship even in the absence of a formal program.

The goal of these efforts is to create a culture of modelling and mentorship which enables students to regularly engage in dialog with their instructors, advisors or counsellors, in which classroom instruction is supplemented by that individual interaction, and through which students develop greater confidence and better skills. Much of what institutions can do to promote mentorship falls within the purview of professional development offices and student services programs and requires their collaboration, and perhaps some redistribution of budgetary resources. That is likely to prove a good investment.

Conclusion

EBCAM education doesn’t adhere to any one learning style or theory, yet uses a multifactorial and multistaged approach with which to impact learners and create self-directed learners [17], so that education may continue long after formal academic settings.  This discussion has identified the attributes of good modelling and mentorship and the characteristics of a democratic learning environment, and has suggested some means by which modelling and mentorship can be strengthened and promoted. Successfully modelled and mentored students transfer that positive experience to successive generations. Successful students and teachers benefit by enriching their experience and developing in their professions. And institutions, which provide strong mentorship, create the kind of positive experiences which build institutional reputations and enrolments, attract superior faculty, and engender the loyalties of supportive alumni associations. Modelling and mentoring makes them better environments in which EBCAM may flourish.

Acknowledgements:  We wish to thank Dr. Carlo Calabrese

References:

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Commentary

This paper outlines key components of learning in medical education in general and specifically with regard to evidence-based complementary and alternative medicine (EBCAM). That is, modelling and mentorship and the characteristics of a democratic learning environment are components of learning in many disciplines and must be recognized as essential to teaching the practice of EBCAM. Didactic teaching and the more Socratic methods may be combined with mentoring and modelling to facilitate the best possible learning.

EBCAM is a relatively new area in medicine. In fact, the term is a bit misleading. Some educational institutions are applying the techniques of evidence-based medicine solely to complementary and alternative (CAM) treatments or preventative measures. But, evidence-based medicine applies to diagnostic, prognostic, treatment, and preventative strategies, among others. With that said, the educational techniques used to train health-care practitioners in EBCAM must be specific to each of these components. I would argue that mentoring, modelling and a democratic learning environment are required for teaching all the components of EBCAM.

If we are going to start to take advantage of the literature, stay up to date, and practice responsible medicine, true EBCAM is the path we must take. To walk this path requires a series of signs, guides, mentors and the proper educational environment that is both challenging and flexible to individual learner’s needs. CAM training institutions should incorporate these methods into their training programs and support the practice EBCAM.

 

Joel J. Gagnier B.A.(Hons), N.D., M.Sc.(Cand. Clin. Epi.)

Deputy Editor, International Journal of Naturopathic Medicine
Associate Professor, Associate Director of Research, Canadian College Of Naturopathic Medicine
CIHR-ONHP Fellow in the Faculty of Medicine, University of Toronto