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The RACGP Curriculum for Australian General Practice 2016

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Curriculum coverThe complete 2016 Curriculum consists of a number of units in addition to contextual units. All units will be available for download as a PDF shortly.

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Integrative medicine

Definition

Integrative medicine refers to the blending of conventional and evidence based complementary medicines and therapies with the aim of using the most appropriate of either or both modalities to care for the patient as a whole. Integrative medicine, like general practice, embraces and encourages a holistic approach to practice that incorporates patient involvement in self healthcare, prevention and lifestyle interventions. Integrative medicine encompasses more than complementary medicine, although this integration is an important and obvious aspect of integrative medicine.

Integrative medicine also describes a style of clinical practice and is best defined as 'the practice of medicine that 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 to achieve optimal health and healing'.1

For the purposes of the RACGP curriculum, complementary medicine will refer to evidence based therapies and medicines that are not conventionally used by doctors, but may complement medical management and be successfully integrated into it – whether the therapy is delivered by a doctor or a suitably trained complementary medicine practitioner.

The National Center for Complementary and Alternative Medicine classifies complementary and alternative therapies, regardless of any supporting evidence base, into five categories or domains.2

Alternative medical systems

Alternative medical systems are built on complete systems of theory and practice. Examples of alternative medical systems that have developed in Western cultures include homeopathic medicine and naturopathic medicine. Examples of systems that have developed in non-Western cultures include traditional Chinese medicine, acupuncture and Ayurveda.

Mind-body interventions

Mind-body medicine uses a range of techniques designed to enhance the mind's capacity to affect bodily function and symptoms. Some techniques, which were considered complementary and alternative therapies in the past, have become mainstream (eg. patient support groups and cognitive behavioural therapy). Other mind-body techniques are still considered complementary and alternative therapies. These include meditation, prayer, mental healing, and therapies that use creative outlets such as art, music or dance.

Biologically based therapies

Biologically based therapies in complementary and alternative therapies use substances found in nature such as herbs, foods, and vitamins. Some examples include dietary supplements and herbal products. Some uses of dietary supplements have been incorporated into conventional medicine, for example, folic acid for prevention of neural tube defects and cholecalciferol when serum vitamin D levels are below normal for the prevention of osteoporosis.

Manipulative and body based methods

Manipulative and body based methods in complementary and alternative therapies are based on manipulation and/or movement of one or more parts of the body. Some examples include chiropractic or osteopathic manipulation and massage.

Energy therapies

Energy therapies involve the use of energy fields. They are of two types.

Biofield therapies involve the existence of energy fields that have not been scientifically proven. Some forms of energy therapy manipulate biofields by applying pressure and/or manipulating the body by placing the hands in, or through, these fields. Examples include qi gong, Reiki and therapeutic touch.

Bioelectromagnetic based therapies involve the unconventional use of electromagnetic fields such as pulsed fields, magnetic fields, or alternating current or direct current fields.

Due to the changing nature of evidence and clinical practice there is a grey area about whether some particular therapies are classified as complementary or conventional.

Curriculum in practice

Typical presentations that illustrate how the Integrative medicine curriculum applies to general practice include:

  • Malcolm, 38 years of age, is a financial controller who presents with problems sleeping. He says he is often tired and, after extensive investigations, you come to the conclusion that there are no serious illnesses contributing to his tiredness. He is now requesting assistance with sleeping, but he says that he doesn't want to take any pills. What approaches can you take?
  • Helen, 52 years of age, is an active woman who presents to her general practitioner. For the past 3 months she has been experiencing mild, but frequent hot flushes and night sweats with associated sleep disturbance. Her last period was 13 months ago. She has been previously well and is taking no medications. She is keen to explore 'natural' management of her menopausal symptoms. What do you advise?
  • Brenda, 28 years of age, is a bank officer. She has been taking warfarin and has a past history of valvular disease. She presents for a routine INR check. She says she is thinking of taking some 'natural supplements', and asks if any of them would interfere with her warfarin.

Rationale and general practice context

A significant driver for integrative medicine has been the rising community interest in complementary medicine. General practitioners need to be familiar with a number of areas within integrative medicine. This may be because the doctor:

  • would like to take an integrative medicine approach to their medical practice
  • needs to be able to discuss integrative medicine or complementary medicine with their patients, including finding out current patterns of integrative medicine use, if any
  • may need to know where to find quality information to answer clinical questions.

Nearly two-thirds of the community have used some form of complementary medicine and many do not disclose this to their doctor. Research has demonstrated as high as 57% of people taking complementary medicines do not tell their doctor and about 50% used conventional medicines on the same day.3 These potentially unsafe situations needs to be addressed.2 4 Patients with chronic diseases are increasingly looking for healthcare outside conventional health systems.

Some doctors may not be confident in dealing with complementary medicine-related issues and may have limited awareness of the evidence base and potential safety issues associated with use. Consequently, they fail to ask patients about use of complementary medicines. Nevertheless, an increasing number of doctors are using complementary medicine or referring patients for complementary medicine.5

Australian general practitioners report6 7 high levels of interest in learning about complementary medicine and the evidence base for these therapies. Over 30% of Australian GPs in a national survey identified themselves as practising integrative medicine and the majority of doctors (>80%) surveyed requested more education and research in complementary medicine.4

There is a higher acceptance of complementary medicines in other parts of the world than in Australia. For example, 64% of medical courses in the United States have content on complementary medicine.8 9 Patients not satisfied with conventional medicine10 often self prescribe complementary medicines without professional supervision emphasising the need for GPs who use integrative medical approaches.

General practitioners who want to pursue more detailed study in integrative medicine need to be familiar with the range, quality and standards, as well as education in this area.

Integrative medicine in general practice

General practitioners are ideally placed to assist patients with integrative medicine due to their broad-based scientific and generalist training and their regular contact with the community.

Comprehensive integrative medicine training aims to:

  • provide a greater range of therapeutic options to patients
  • help patients make safe and balanced decisions regarding complementary medicine use
  • avoid potentially harmful interactions between complementary and conventional therapies.

Integrative medicine does not reject or compete with conventional healthcare and overlaps significantly with what is currently widely accepted as quality general practice. Integrative medicine seeks to broaden conventional healthcare by emphasising principles that some doctors and patients believe are undervalued in conventional medical practice. Integrative medicine emphasises a number of issues including:

  • a focus on wellness and illness prevention
  • being holistic in nature by focusing on physical, psychological, spiritual, social and lifestyle issues
  • incorporating evidence based, safe and ethical complementary therapies
  • individualising the approach to any particular patient or clinical situation using the best of all available modalities in conjunction with informed patient choice
  • integrating all of the above into conventional medical care
  • acknowledging that advances in healthcare will be dependent on scientific advances, improvements in healthcare delivery systems, cultural change as well as practitioner and patient education.

A comprehensive approach to integrative medicine involves more than adding a little complementary knowledge to the 'kit bag' of the GP. Integrative medicine incorporates a philosophy of healthcare, as well as a way of practising. Prevention, holism and informed patient choice are obviously integral to the whole of general practice, and therefore the complementary aspects are often given the most attention when considering what integrative medicine is.

For this reason, integrative medicine training is not seen as a separate or stand alone aspect of general practice training. Some aspects of integrative medicine may be taught as stand alone modules, or in integrative medicine seminars and case discussions, but are best understood and applied when integrated appropriately into other aspects of general practice training. For example, when a doctor is learning about the management of depression or cardiovascular disease, training and case studies should integrate important principles of integrative medicine.

Related curriculum areas

Refer also to the curriculum statement:

Training Outcome of the five domains of general practice

1. Communication skills and the patient-doctor relationship

INTT1.1

Communicate effectively with patients about integrative medicine, including taking a nonjudgmental history about the use of complementary medicines and self care issues, while responding to a patient's context in terms of history, culture, gender, race, spirituality and personal choices.

INTT1.2

Assist patients to make decisions about their philosophy of healthcare and what treatment modality is best for them.

INTT1.3

Be able to refuse unreasonable requests and set limits for patients.

INTT1.4

Effectively communicate some integrative medicine skills, for example, relaxation techniques.

2. Applied professional knowledge and skills

INTT2.1

Know the definitions, philosophy and main modalities of integrative medicine.

INTT2.2

Have a basic, broad knowledge of the integrative medicine field, as well as the principles for appropriate use in conventional medical practice.

INTT2.3

Be aware of the current evidence for widely used complementary medicines.

INTT2.4

Know important interactions and side effects (common and/or severe) associated with complementary medicines.

INTT2.5

Have the necessary skills to implement behaviour change and lifestyle strategies.

INTT2.6

Know how to access quality sources of information on integrative medicine to suit both therapist and patient needs.

INTT2.7

When appropriate, know about or how to use a number of complementary modalities, which are safe and well supported by evidence. Know how to deal with situations where knowledge is lacking and how to access quality information to help guide clinical decisions. This may not apply to all GPs.

INTT2.8

When appropriate, manage common conditions using or offering complementary medicines. Also develop an integrative management plan for patients with chronic and complex illnesses, including combining complementary and conventional medicine. This may not apply to all GPs.

3. Population health and the context of general practice

INTT3.1

Know the usage patterns of integrative and complementary medicine in the community.

INTT3.2

Be aware of attitudes and cultural factors (such as the use of traditional Chinese medicine in the Chinese community) toward the use of complementary therapies, both in the community and the medical profession.

4. Professional and ethical role

INTT4.1

Adopt appropriate clinical attitudes toward complementary therapies including respect, openness and tolerance for patients' choices and experiences. Also display these attitudes to nonmedical complementary practitioners while giving advice and direction when choices may be unsafe, as for any informed consent process.

INTT4.2

Recognise presentations that require more intensive or specialised integrative medical management.

INTT4.3

Be able to deal with interdisciplinary issues and communicate with medical and nonmedical complementary practitioners.

INTT4.4

Apply general ethical principles to integrative medical clinical situations.

INTT4.5

Be aware of professional legislative requirements and regulations regarding complementary medicines.

5. Organisational and legal dimensions

INTT5.1

Maintain an awareness of medicolegal issues relating to integrative and complementary medicine issues.

INTT5.2

Be up-to-date with current laws and regulations regarding the use of complementary medicines including medical indemnity implications.

Learning objectives across the GP professional life

Medical student

1. Communication skills and patient-doctor relationship

INTLM1.1

Demonstrate an ability to take a history about the use of complementary therapies in a nonjudgmental manner.

2. Applied professional knowledge and skills

INTLM2.1

Define integrative medicine and complementary medicine.

INTLM2.2

Describe the philosophy of integrative medicine.

INTLM2.3

Describe the main modalities of integrative medicine.

INTLM2.4

Describe the current evidence and risks of widely used complementary medicines.

3. Population health and the context of general practice

INTLM3.1

Describe the general safety issues of complementary medicines.

INTLM3.2

Describe the community usage and attitudes toward integrative medicine and complementary medicines.

4. Professional and ethical role

INTLM4.1

Describe the principles for the appropriate use of integrative medicine in conventional medical practice.

5. Organisational and legal dimensions

INTLM5.1

Describe important integrative medicolegal and ethical issues.

Prevocational doctor

1. Communication skills and patient-doctor relationship

INTLP1.1

Demonstrate an ability to assist patients to make decisions about what treatment modality is best for them.

2. Applied professional knowledge and skills

INTLP2.1

Demonstrate management of common conditions using or offering integrative medicine where appropriate.

INTLP2.2

Describe important interactions and side effects (common and/or severe) associated with complementary medicines.

3. Population health and the context of general practice

INTLP3.1

Outline the impact of integrative medicine on the community and medical profession.

4. Professional and ethical role

INTLP4.1

Demonstrate application of ethical principles to simple clinical situations involving complementary medicines.

INTLP4.2

Describe how to deal with interdisciplinary issues.

5. Organisational and legal dimensions

INTLP5.1

Demonstrate ability to effectively communicate with medical and nonmedical integrative and complementary medical practitioners.

Vocational registrar

1. Communication skills and patient-doctor relationship

INTLV1.1

Demonstrate ability to deal with unreasonable requests and set limits for patients during consultations.

2. Applied professional knowledge and skills

INTLV2.1

Demonstrate how to develop a management plan for patients with chronic and complex illnesses, where appropriate, by incorporating integrative into conventional medicine.

INTLV2.2

Identify and manage important interactions and side effects (common and/or severe) associated with complementary medicines and therapies.

3. Population health and the context of general practice

INTLV3.1

Refer important interactions and side effects (common and/or severe) associated with complementary medicines and therapies.

4. Professional and ethical role

INTLV4.1

Apply ethical principles to more complex clinical situations involving integrative and complementary medicines.

5. Organisational and legal dimensions

INTLV5.1

Describe the legislative requirements and regulations regarding complementary medicines.

INTLV5.2

Identify presentations requiring more intensive or specialised integrative medical management.

INTLV5.3

Understand the medicolegal and indemnity issues related to the use of complementary medicine.

Continuing professional development

1. Communication skills and patient-doctor relationship

INTLC1.1

Demonstrate regular review of gaps in communication skills in integrative medicine.

2. Applied professional knowledge and skills

INTLC2.1

Review professional knowledge areas in integrative medicine, especially around advances in complementary medicines.

INTLC2.2

Review the need for any ongoing educational activities in integrative medicine.

INTLC2.3

Outline the role of the RACGP National Faculty of Specific Interest – Integrative Medicine.

3. Population health and the context of general practice

INTLC3.1

Demonstrate regular review patterns of complementary medicine use.

4. Professional and ethical role

INTLC4.1

Reflect and act on professional development needs in integrative medicine including QI&CPD activities.

5. Organisational and legal dimensions

INTLC5.1

Demonstrate regular review of links with integrative and complementary medicine practitioners.

INTLC5.2

Demonstrate regular review of medicolegal and indemnity requirements for integrative and complementary medicines.

References

  1. Consortium of Academic Health Centres for Integrative Medicine. Definition of integrative medicine. 2009. Available at www.imconsortium.org/about/home.html.
  2. National Center for Complementary and Alternative Medicine. What is complementary and alternative medicine? Available at www.nccam.nih.gov/health/whatiscam.
  3. MacLennan AH, Myers SP, Taylor AW. The continuing use of complementary and alternative medicine in South Australia: costs and beliefs in 2004. Med J Aust 2006;184:27–31.
  4. Brown J MT, Adams J, Grunseit A, et al. Complementary medicines information use and needs of health professionals: general practitioners and pharmacists. Sydney: National Prescribing Service; 2009.
  5. Kotsirilos V. GPs attitudes toward complementary medicine. Aust Fam Physician 2007;36:270–1.
  6. Cohen MM, Penman S, Pirotta M, Da Costa C. The integration of complementary therapies in Australian general practice: results of a national survey. J Altern Complement Med 2005;11:995–1004.
  7. Pirotta MV, Cohen MM, Kotsirilos V, Farish SJ. Complementary therapies: have they become accepted in general practice? Med J Aust 2000;172:105–9.
  8. Wetzel MS, Eisenberg DM, Kaptchuk TJ. Courses involving complementary and alternative medicine at US medical schools. JAMA 1998;280:784–7.
  9. Consortium of Academic Health Centres for Integrative Medicine. 2011. Available at www.imconsortium.org.
  10. Astin JA. Why patients use alternative medicine: results of a national study. JAMA 1998;279:1548–53.

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